[00:00:00] Speaker A: KPI Sam, don't.
[00:01:02] Speaker B: You're tuned to KFAI, 90.3 FM, Minneapolis, and KFai.org. You are listening to disability and progress, where we bring you insights into ideas about and discussions on disability. Top Fix My name is Sam. I'm the host of this show. Thanks so much for tuning in. Charlene Doll is my research woman. Hello, Charlene. Good morning, everyone.
[00:01:23] Speaker A: Good evening.
[00:01:25] Speaker B: Well, it's still morning, but that's okay. This week we're speaking with Dr. Stuart Bloom, and Dr. Bloom is going to be talking about breast cancer. And although October is National Breast Cancer Month, I feel like it's important to be able to discuss this topic whenever we can get someone on to talk about it. Dr. Bloom is an assistant professor of medicine at the Medical University of Minnesota in the Twin Cities, on the Twin Cities campus. He also specializes in breast and prostate cancers, and he is also a member of the Masonic Cancer center and a physician at the MHealth Fairview. Thanks for joining us, Dr. Bloom.
[00:02:12] Speaker A: Thanks for having me. It's a privilege.
[00:02:15] Speaker B: I want to just talk a little bit about your journey and how you happened to get into breast cancers and prostate cancers.
[00:02:24] Speaker A: Well, I went to medical school later in life.
I started off wanting to be a rich and famous actor. Really?
[00:02:33] Speaker B: Did you?
[00:02:34] Speaker A: Yes.
Had you heard of me? Clearly didn't quite work out that way. But I lived in New York City in my twenty s, and I was an actor and a comedian. And I worked enough to know what it felt like to be a working actor there, but enough not to realize I didn't want to. You didn't want to be the rest of my life? Yeah, that's true.
And then I turned 30. I realized I wasn't rich and famous. And then my own father was diagnosed with stomach cancer.
So my wife and I came back to Minneapolis. She's from here, too. And we had our two young kids at the time. And I saw him after surgery and just with all those things of like, oh, my know, somebody who's one of the very centers of your life may not be here. And it just kind of caused great soul searching and kind of, what is life all about? And then my wife Carolyn, was reading a book. I just finished a book by a cancer doctor about his work. And she said, well, take a look at this. And I read the book.
It is called Love Medicine and Miracles by a guy named Bernie Siegel, cancer Surgeon from Yale. And I read the book. I closed the book and I said to know, I think I should be an, you know, to Carolyn's great.
Yeah, I think you'd be a great. So.
But of course, I hadn't had a science class since I was in high school, and I was three years old at this point. So I went down to the medical school and I asked one of the deans of admission. I said, so how do you get into medical school?
And do you even accept people in their 30s, Eddie? He said, oh, of course, yes.
Here's what you need to do to get into medical school. You need to take a year of physics, a year of chemistry, a year of organic chemistry, a year of calculus, and a year of biology. And it would help to have some biochemistry.
Well, I have not had a science class forever, but a very long story, very short, it clicked in my head, and I did pretty well. We moved back to Minneapolis, and I started medical school at the university at 33, finished at 37, and I did my internal medicine residency at Hannah County Medical Center.
And then I did my cancer training at the university. And while there, I worked very closely with Dr. Douglas Yee, who is one of the national leaders in breast cancer. And I was his fellow. I worked very closely with him. I massaged his temples. I got his pants done for him. Just kidding about those last two things.
And he really turned me on to the amazing world of breast cancer. And so when I left my training in 2001, I was essentially, I wanted to do mostly breast cancer.
And I started at North Memorial at that point and worked with a great Dr. Harold Launder in that group and just learned a lot about how to do it. And then I started getting prostate cancer 20 years ago. There wasn't much to be done, but it's a hormonally driven cancer, kind of like breast cancer is. And so I found it very fascinating.
And then breast cancer now is this enormously complicated thing. Yes, but the truth is, Sam, if you've been part of, what if you started when it was simple, and then year by year, a new layer is added? Well, 20 years later, there's 20 new layers, but you absorbed each layer. And so part of my role at the university is to simplify the teaching of breast cancer to our soon to be oncologists.
[00:06:35] Speaker B: As you say, that's a long winded answer to your. That's a great answer.
What a great story.
[00:06:42] Speaker A: I just made it up, but it sounds great, really.
[00:06:49] Speaker B: So, as you say, breast cancer is a pretty broad topic. How many different kinds of breast cancer are there?
[00:06:56] Speaker A: I think that's a great question, Sam, because in the past, when people say they have cancer, they usually say, well, I have breast cancer or I have lung cancer, but we really should refer to it. The way that you even asked your question was very insightful. We should think of it as breast cancers and not breast cancer, because there are these things called genes, and the genes kind of correlate with how aggressive a cancer is. And it turns out if you do a gene array, a testing of each breast cancer, they're all going to be kind of subtly different from each other, the way that fingerprints are.
But you can be either a lumper lump things together, or a splitter and spread things apart. So in breast cancer, you have to be a little bit of a lumper and a little bit of a splitter.
So just because everybody's cancer has probably some slightly different gene expression, for the most part, we kind of talk about maybe six or seven different types of breast cancer these days.
But of course, there's also subtle differentiations between them.
[00:08:04] Speaker B: How does DCIS relate to breast cancer?
[00:08:08] Speaker A: Oh, DCIS is a great, great question. So DCIS is not cancer, but you listen to the title of it, or you look at what it is. D stands for ductal, C stands for carcinoma, which means cancer. Right, but I means in and S means Cytu. Incytu means not invasive.
Well, cancers, by their very definition, Sam, are invasive. And so this is a cancer that's not a cancer. It's kind of like an oxymoron, kind of like jumbo shrimp.
[00:08:46] Speaker B: People panic when they get. They do, and should they?
[00:08:52] Speaker A: They really shouldn't, because if somebody has a diagnosis of DCIS, remember, that's a pre cancer, it would be the same thing if somebody had a colonoscopy and had a precancerous polyp. So when you get colonoscopies to try to find things that could become cancer, and then you remove those things, and then those people don't get cancer, it's the same holds true for DCIS. DCIS is not cancer.
We think for most people, or at least many people, if we don't treat the DCIS, if we don't remove the polyping, colon cancer, if we don't treat the DCIS, then maybe it could become breast cancer. So the goal of therapy for DCIS is to remove the DCIS and decrease the chance of developing invasive cancer. But it's very clear that if you take a huge population of women who had DCIS and another huge population of women who are exactly equal to everybody in the DCIS population, with the sole exception is they don't have DCIS, they both live for the same amount of time, and they both have the same risk of dying of breast cancer. So DCIS, part of what our great mission is at the university is to tone down the tenor of stress that is associated with the DCIS diagnosis. In fact, there's a clinical trial that we have ongoing that when women are diagnosed with DCIS, and if it's a certain kind of DCIS, sometimes they don't even get surgery, they just go on a pill.
[00:10:34] Speaker B: And is that a hormone type?
[00:10:38] Speaker A: If it's. If the estrogen receptor in the DCIS.
[00:10:42] Speaker B: Is positive, can you talk about hormone positive breast cancers? Because there's different ones. So give us a little bit of.
[00:10:53] Speaker A: Info about that, okay, and tell me to shut up if I'm getting too.
[00:10:56] Speaker B: No, you're all good.
[00:11:01] Speaker A: Ever since the understanding about hormone receptor positive breast cancer goes way, way back to.
I don't know exactly, I think it was like the 19 hundreds. But it was clear that there was this woman, a young woman, a premenopausal woman, had a very bad breast cancer.
And it wasn't clear exactly what to do to help this woman. And somebody got the idea from veterinarians that they knew that if there were tumors on a cow's utters, if they removed the ovaries of those cows, those tumors went away.
Isn't that interesting? So that implies that because ovaries make estrogen. So they took this woman with the advanced breast cancer, who was premenopausal and removed her ovaries, and lo and behold, her cancer got better.
So that was one of the first. And the guy who published this was a guy named Dr. Huggins. And this is kind of well known in breast cancer, the annals of breast cancer history. And that was the first kind of evidence that estrogen can stimulate the growth of some breast cancers. And so now fast forward to 150 years later, or wherever we are now, we know that there are certain estrogen receptor positive breast cancers that are driven solely by estrogen. So if the breast cancer is a car and the accelerator pedal is the estrogen receptor, and estrogen is the foot that puts its foot on the accelerator pedal, well, if you block estrogen, then that accelerator never gets pushed, and those cancers weaken and then die. So that is one kind of estrogen receptor positive breast cancer that responds very well to hormonal therapy.
Okay, go ahead.
[00:13:02] Speaker B: That's okay. That's part of the treatment, is blocking the hormones. How long can you do that treatment?
[00:13:13] Speaker A: I'm just going to finish the thought from before, and then we'll answer that really important question. So the thing is, so some people who do very well with hormonal therapy, because before your question was like, how many? Are there different types of estrogen receptor positive breast cancer? Yes. And, Sam, it became clear that there are some people that you can just treat with the hormonal blockade that we just talked about, and they do great. Some people with an estrogen receptor positive breast cancer, you treat with estrogen receptor blockade, and guess what? It doesn't work as well. But they're the same cancer. Right? But no. So it turns out if you really look at gene expression, they have a different set of genes.
So the next question you just asked was, how long can you be on these drugs? Right.
[00:13:55] Speaker B: Right.
[00:13:56] Speaker A: Okay.
Should I talk a little bit about why people even need to go on drugs after surgery?
[00:14:06] Speaker B: Yeah, some people don't. Yeah, why don't you talk about that? I guess that would be in the treatment of hormone breast cancer, right?
[00:14:14] Speaker A: Yeah, it is. Absolutely.
[00:14:16] Speaker B: Go for it.
[00:14:17] Speaker A: So when somebody has a breast cancer, here's the truth. The vast majority of people with an early stage breast cancer will be cured of their cancer. Yay.
[00:14:25] Speaker B: And when you say early stage, what does it consist?
[00:14:29] Speaker A: That means that it hasn't obviously spread beyond the breast and the local lymph nodes.
[00:14:34] Speaker B: Okay.
[00:14:35] Speaker A: So it's not in the bones or the liver or the lungs.
Again, kind of going way back, people would do surgeries for people with breast cancer, and some were cured and some were not.
And why was that? Well, it turns out breast cancers, as all cancers are, they're sneaky, right? Even before you know they're there. Kind of the way, like dandelion seeds in someone's backyard can get blown into the wind and then go to different places in the yard. Cancer cells can get into the bloodstream and spread beyond the breast even before you know it's there. And so if you do surgery on somebody that has had these microscopic breast cancer cells already gotten into the bloodstream, well, you can remove the breast cancer and the involved nodes. Yeah, you should do that. But there's a chance that there's some microscopic cancer left behind. And that's why people go on treatment, to try to find those rogue cancer cells that have spread beyond the breast, find them and kill them, and increase the chance of cure. So your question was, how long do people have to be on these drugs? Well, it turns out the longer that people are on these drugs, there is a higher chance of cure. But remember what I said, too, that the vast majority of people probably don't even need these drugs. So it would be really great if we had a test that we could go in the bloodstream and say, oh, look, you have microscopic breast cancer cells elsewhere. You are the one who needs the treatment, Sam, we don't have that treatment yet. We don't have that way to assess it yet. We do have the treatment and it's these hormonal therapies.
But if the risk of cancer coming back, the risk of having these microscopic cells getting into the bloodstream, is directly related to how big the cancer is. The larger the cancer, the more chance of having microscopic cells elsewhere in the body or how many nodes are involved. The more nodes involved, the more chance of having microscopic cells spread in other places in the body. And so those are the people whose cancers can come back eight years later, twelve years later, and things like that. So those are the ones that you hope you can keep on the hormonal therapy for longer than kind of what used to be standard five years.
[00:17:02] Speaker B: Yeah.
And can you keep them on for longer than five years if they're responsible?
[00:17:07] Speaker A: The thing is, we can prescribe it. So there's some very good data about non compliance with these drugs.
There's a wonderful oncologist from New York whose name is Dawn Hirschman and she has done a lot of research on this. So if there's a place kind of like a Park Nicholas in California called Kaiser Permanenti, I don't know if you.
[00:17:29] Speaker B: We've heard of it, yeah.
[00:17:31] Speaker A: So Kaiser Permanenti did. They surveyed 9000 of their patients with breast cancer and they wanted to see how compliant they were with two different kinds of hormonal therapy. One is tamoxifen and one are these drugs called aromatase inhibitors. So just take a guess.
What is the compliance rate like? Is it 100%? You give it to ten people and all ten remain on it for ten years, or you give it to ten and two people stay on it. I mean, how much do you think is the compliance with?
[00:18:08] Speaker B: I would guess 50%.
[00:18:11] Speaker A: Yeah, that's really good. That's very close.
For the tamoxifen, it was about 60%, meaning four out of ten People that you prescribed tamoxifen to didn't take it because they didn't like the side effects. And aromatase inhibitors, like an astrozol or lectrozol or XMsdane are even worse. And by the fourth year, only about a third of the people are taking these drugs because they have really annoying side effects.
[00:18:35] Speaker B: And what are the side effects?
[00:18:37] Speaker A: Hot flashes with tamoxivin Sometimes it's weight gain with aromatase inhibitors, it's joint know, vaginal dryness. There's just a lot of annoying side effects that make these drugs difficult to take.
[00:18:54] Speaker B: Dr. Bloom, you gave just a really good explanation on hormone driven breast cancers. I'd like to talk about the other side of it and talk about the triple negative breast cancer. Tell me a little bit about that, because that's different.
[00:19:10] Speaker A: It is different.
Again, it's just a different disease. And when we talk about breast cancers, so triple negative means, if it's triple, it's got to be negative for three things. So it means it's negative for the estrogen receptor. It's negative for something called the progesterone receptor, and then it's also negative for her two new amplification, which is a whole different breed of breast cancer as well. And so it was pretty well known that if somebody had triple negative breast cancer, wow, they had a worse prognosis because couldn't use all those hormonal therapies. Right. They do not work.
And so 20 years ago, all we had for this type of breast cancer was chemotherapy. And chemotherapy is not, well, it's still useful in 2023. It is certainly not something that we want to continue using in 2033 or 2043, because chemotherapy works by indiscriminately getting in the way of cells that divide fast and can kill those cells that divide fast.
So if breast cancer cells divide fast, you give them chemotherapy. Those cells take up the chemotherapy and they think that they're dividing, but the chemo fools them and then they crack open and then they die. But there's also normal cells of the body that divide fast, too, and they get temporarily damaged by the chemotherapy like cells of the follicles. Right. You lose your hair for many people, or the cells that make the white blood cells that help you fight infection, those get temporarily damaged, sometimes taste, too, right?
Say that again.
[00:20:56] Speaker B: Taste.
[00:20:58] Speaker A: Taste, sure. Oh, my God. There's all these other things that aren't taste changes, nail changes, rash, constipation, diarrhea. The same regimen that causes one person constipation causes another one diarrhea. You can't even predict it. But there's just a long list of side effects. And the good news about those side effects is the vast majority are temporary, and people only want to do that for the chance of living longer. Right. Having a higher chance of cure.
Well, so just like we can target the estrogen receptor in breast cancer, in estrogen receptor positive breast cancer and give hormonal therapy to those people, people who have triple negative breast cancer. It turns out just because it's negative for ERPR in her, too doesn't mean it's negative for everything. And actually, there are really good targets in triple negative breast cancer that we are using. For example, often we can use some immunotherapy, we can talk about immunotherapy. But immunotherapy tends to work for a number of triple negative breast cancers.
And often triple negative breast cancers are associated with people who have BRCA mutation. And if that's true, then you can use these special targeted therapies called PARP inhibitors. I mean, there's a lot of different things that can be done about triple negative breast cancer. We try to find targets for triple negative breast cancer and use targeted therapy against those.
[00:22:35] Speaker B: Dr. Bloom, I used to hear, actually, this is a question from my research person, but both of us used to hear about smoking being attached to not only lung, but breast cancer.
Smoking presumably has gone down. Is it still attached to breast cancer? How does that work?
[00:22:55] Speaker A: That's a good question. And the big answer for me is, I don't know. So I'll always be honest with you, but it's pretty clear that when people smoke, they have a higher risk of a whole lot of cancers. And it's not just lung cancer.
Smoking is still bad for you. It's been in all the papers. I mean, I tell that to smoke. So you're still smoking, I see.
Have you heard it's bad for you? It's been in all the papers.
But smoking can also lead to bladder cancer. I mean, there's all these, maybe a little bit, slightly increased risk of hematologic cancers, blood cancers. But the number one cause of death from cancer in women is still lung cancer, but the number two cause is breast cancer.
[00:23:42] Speaker B: And so how does vaping play a role?
[00:23:46] Speaker A: I have to be honest with you.
[00:23:48] Speaker B: I don't know because it's so new still, it's been out for a while.
[00:23:53] Speaker A: Well, it's not my wheelhouse. Right. I take care of people with breast cancer and prostate cancer, and vaping has not really, to my knowledge, been associated with those two cancers. I don't think vaping is healthy for you.
[00:24:06] Speaker B: No.
Can you talk a little bit about it?
They talk about lumpectomy as opposed to mastectomy. Lumpectomy being like you talked about, just removes the cancer or the spot in the breast. Mastectomy removes the entire breast. Tell me a little more about what goes into that decision.
[00:24:28] Speaker A: So it's very clear that a mastectomy as compared to a lumpectomy and radiation, and you need the radiation. If you're getting a lumpectomy to the breast, they have the exact equal high chance of cure.
And lumpectomy is less aggressive, so it's a boon for women. Mastectomies are more aggressive. You have to have a drain in. There's lots of other things that often people get reconstruction, which is another 17 more surgeries.
The medical term is morbid, but it just has more side effects.
So if they both have the same high chance of cure and one is less aggressive and has less side effects, then often people opt for the therapy that has fewer side effects.
So to be considered for a lumpectomy, the goal of cancer surgery is to remove all of the cancer, but in a way that leaves someone still okay with the remaining breast, the look and shape of the remaining breast.
So that's a conversation between the surgeon and, I'm not a surgeon, I'm a medical oncologist. That's a conversation between the surgeon and the patient. And they get to see that. The surgeon decides, well, if I remove this lump, your breast will look a certain way, and it's usually cosmetically acceptable to many people, and so they'll get a lumpectomy. Some people, Sam, are not candidates for lumpectomy because the tumor is too big and they don't have enough normal breast outside of that tumor. And so those people who still want to have a lumpectomy, we give actually the systemic therapy upfront.
It's called neoadjuvant therapy. And depending on the biology of the cancer, we can often shrink down the cancer to the point where somebody who was just a candidate for a mastectomy, they could get a lumpectomy.
[00:26:51] Speaker B: Interesting.
You mentioned chemotherapy, which is something that's used in breast cancer.
And I was going to ask if chemotherapy is different with different breast cancers, but that probably is kind of obvious that you would give maybe one chemotherapy for hormone positive and another for triple negative. But I wonder if somebody is hormone positive, if there would be even different chemotherapies for that, the same with hormone negative, or is it just one protocol?
[00:27:31] Speaker A: That's really interesting. That's a really good question. Because the thing is, if somebody remember the reason why a hormone positive patient would get chemotherapy is that they have the type of estrogen receptor positive breast cancer that still has a risk of coming back despite the hormonal therapy. So these are cells that don't respond if somebody had an estrogen receptor positive breast cancer. So there are names for these types, luminal A is breast cancer, that is estrogen receptor positive. And people do well with hormonal therapy. Luminal B are patients with estrogen receptor positive breast cancers who, if you just give them endocrine therapy alone, hormonal therapy alone, they have a significant chance of their cancer coming back.
So in luminal B, breast cancer, the ones that we give the chemo to, we have to kind of think as, what is the biology of the cancer cells that would not respond to the hormonal therapy?
And there are these protocols that have been developed over time that when I first got involved in this 20 years ago, it was all about the different chemotherapy regimens, right? They were all a bunch of letters. CMF versus AC. Well, AC is maybe the equivalent, maybe slightly better, and it's only four months versus six months, and then AC versus TC, and then TC probably wasn't better. It's slightly better, and there's no risk of heart damage. So there's all these kind of alphabet soup of letters.
And the alphabet soup, where the alphabet soup has led to in 2023, is that when somebody has an estrogen receptor positive breast cancer, they tend to get this regimen called TC, which is taxoter and cytoxand, because studies have shown that it probably works the best in that luminal B breast cancer setting has the highest chance of cure with the least chance of long term side effects.
[00:29:35] Speaker B: But maybe not for triple negative.
[00:29:38] Speaker A: No, triple negative breast cancer. You have to do more. Exactly. So you probably would add potentially heart toxic therapy called adriamycin doxyrubicin. That is something that is often added. And sometimes we add carboplatinum platinum direction. There's a different set of things that happen. You sound like you have some experience with it.
[00:30:03] Speaker B: How does radiation play into the breast cancer?
[00:30:09] Speaker A: So radiation is like surgery in that they are what we call local therapy. They're done in one location on the body.
So surgery is done on one location. Radiation can only work where it is flashed. And so radiation is done on one part of the body. So radiation and surgery. So the way to lump it, to think about it in your head, Sam, is that radiation and surgeries are what we call local therapy, just done in one location. Anything a medical oncologist gives, either by mouth or in the vein, is what we call Systemic therapy. It goes in the system.
So radiation is very important in terms of lumpectomy, because lumpectomy and radiation, remember, are the equivalent of mastectomy. Lumpectomy by itself is not the equivalent of mastectomy, because often there are some microscopic breast cancer cells away from the tumor that could grow unless you radiate them.
[00:31:14] Speaker B: So radiation generally has been paired with treatment of breast cancer. If one cannot have radiation, then I'm presuming you move more towards the mastectomy.
[00:31:27] Speaker A: Yes, unless there's some big unlesses here, unless the patient is at the advanced age of 65 or over and I'm 65.
So it turns out if you have aluminal, a breast cancer, a hormone driven breast cancer that does very well with hormonal therapy, and it's not node positive, well, you could have a lumpectomy, and instead of going with radiation, you can go on tamoxifen or an aromatase inhibitor, and your chance of cure is the same. Your chance of distant, your chance of cancer showing up elsewhere outside of the breast is the same.
There's a slightly increased risk of having to need more surgery to the breast if you don't get radiation, but you could just have more surgery and it doesn't have to be a mastectomy. So that's kind of standard therapy for women of my age and above who are estrogen receptor positive, node negative, who just get a lumpectomy. You can actually avoid radiation in those if they have an estrogen receptor positive breast cancer.
[00:32:37] Speaker B: But the triple negative is different, hip.
[00:32:40] Speaker A: Pill negative is a different disease.
So if it's a small triple negative breast cancer, you would still radiate the breast.
[00:32:49] Speaker B: What if they can't do it?
[00:32:52] Speaker A: If there's something because they have like scleroderma or some, or something that prevents.
[00:32:58] Speaker B: Them from getting the radiation?
[00:33:01] Speaker A: Well, then probably you would go for a mastectomy.
[00:33:04] Speaker B: I think immunotherapy is one of those, it feels like kind of late ish in the game things they've found, but it's not a cure all. Why can they not just use the immunotherapy?
[00:33:20] Speaker A: That is a great question.
So let's talk a little bit about the immune system and how it works.
[00:33:28] Speaker B: Yes, please.
[00:33:29] Speaker A: Every time you or I have gotten infected with a virus, flu, COVID, a cold, or a bacterial infection like strep, we AlwayS get better. And why is that? Well, we always get better because we have this thing called the immune system. And the immune system's job is to recognize foreign Invaders, the things that infect uS.
So the immune system recognizes that foreign invader. Once it recognizes the foreign invader, it makes a protein called an antibody that sticks to the outside of that very foreign invader. And then the third part is anything coated with antibodies, our immune system recognizes and then destroys. So why doesn't our immune system recognize our cancer as a foreign invader?
Here's why, Sam. The immune system bumps up against the cancer, and the cancer is this diabolical thing. It pushes on the immune system and says, hey, I'm not foreign, I'm you. And so then the immune system goes, oh, and then moves on. So the molecule that does that, that tells the immune system to move on is this thing called PDL one.
Well, it turns out if you get rid of PDL one, then the immune system can recognize the patient as a foreign invader and then start attacking the cancer. So not every cancer has a lot of this PDL one. There are other molecules, too, obviously, that mediate this. But there are some triple negative breast cancers that are overexpressed for PDL One. And those are the ones who get the immunotherapy. But they do have side effects, because if you think about it, if you think about it, you're trying to turn your immune system on, to recognize yourself as foreign, so it can destroy the cancer.
[00:35:35] Speaker B: Right.
[00:35:36] Speaker A: What's to keep the immune system from recognizing parts of you that isn't cancer as foreign?
[00:35:42] Speaker B: What is to do that?
[00:35:43] Speaker A: Nothing. So it turns out many people who get these drugs have big rashes. Many people who get these drugs have a lot of diarrhea because the immune system starts recognizing the lining of the bowel is for, it's not a free lunch, but it turns out there are some people who do extraordinarily well with it without developing a lot of side effects. And we're not really quite sure why that is.
[00:36:08] Speaker B: Genetic?
[00:36:09] Speaker A: That's the story, yeah, probably other genes, I'm sure. We just don't know which genes those are.
[00:36:15] Speaker B: So they can't use the immunotherapy by itself. So they use the.
[00:36:22] Speaker A: Right.
There are certain cancers that are not breast or prostate that you can actually use immunotherapy by itself.
Diseases like melanoma or bladder cancers, urethelial carcinomas, you can actually use the immunotherapy by itself.
In breast cancer, we have not really done that.
That has not been shown to be as much benefit as it is if you add some chemotherapy to it.
[00:36:52] Speaker B: Can you talk about genetic testing? There's a lot of stuff that I feel like gene testing is being done more and more now.
Certainly the Braca gene has been recognized for a while, but now you can pretty much do all of your genes. So how does this relate to any pre knowledge of how big your breast cancer chances might be. Or even at the time that you get breast cancer, if you get tested for genes, does that determine the treatment that you're going to get? Can you talk about.
[00:37:40] Speaker A: Those are, these are really great questions, Sam.
[00:37:42] Speaker B: Thank you.
[00:37:43] Speaker A: Sure. So there's two different kinds of ways that we're doing gene testing in our clinic. When somebody has a diagnosis, one is to check what we call germline testing. Check their cells. Like if they have. Just take one of their. Take a swab from the cheek, because remember, every cell has all the complement of DNA that you have in your entire body, and run some DNA chest testing on that to look for inherited predispositions to cancer.
[00:38:13] Speaker B: Okay.
[00:38:14] Speaker A: Like BRCA. BRCA wanted to like ATM. There are all these other. Check two. There are all these genes that increase the risk of getting breast cancer. And that's helpful for a patient because if they have a high risk of. If they have one of these genes, they have a high risk of having cancer on the other side at some point. So sometimes those people opt for bilateral mastectomy.
Then the second way that we are checking genes in the clinic when somebody's diagnosed with breast cancer is we actually look at the genes of the cancer, which is different than genes of the person.
Sometimes they have the same, like, if it's a BRCA positive patient, it's very likely their tumor will have BRCA abnormalities. But we also look for things that we can target, too.
I think the crux of your question was about kind of your own germline testing if somebody is an inherited predisposition to breast cancer. Well, we used to only look for BRCA one and two, and now when we send people for gene testing, we look for 86 different genes or something like that. It's just amazing. Some of those genes are still what they're called, variants of unclear significance, meaning that we don't really know how much that increases the risk of breast cancer. But all this is important for people because they have children, right?
[00:39:41] Speaker B: Right.
[00:39:41] Speaker A: And knowledge is power. And if you possess a gene, there's a 50% chance that one of your children does.
And if they should be tested, and if they haven't, then they should be. In terms of breast cancer, they should be screened on a heightened screening schedule, with MRIs alternating with mammograms. They could consider prophylactic surgery if they want to. I mean, there's a lot of options for people who find out that they do have these inherited predispositions to breast cancer.
Sometimes it also includes a predisposition to ovarian cancer, like BRCA patients. And so they sometimes get their tubes and ovaries removed as well to prevent the development of ovarian cancer.
[00:40:27] Speaker B: So with all the treatments, and mean, obviously the treatments have popped up that have been much more numerous than, let's say, 20 years ago, have the survival rates actually changed?
[00:40:42] Speaker A: Sure they have, in a major way. There's less people dying from breast cancer than ever. And more importantly, too, when people have breast cancer that has come back, they live for much longer than they would have otherWise. We have people who are alive 1015 years later. I just saw one of my patients whose first relapse elsewhere in the body was in 1994 for 2023. So it's pretty amazing. Yes.
All of the research, all of the stuff that has happened has resulted in better outcomes for people with breast cancer.
[00:41:23] Speaker B: And what about the numbers of people with breast cancer? Are they going down or are they going up? Or is it just that we're recognizing more varieties of breast cancer?
[00:41:34] Speaker A: Yeah. So it was pretty clear that after you and I are both probably old enough to remember this, when everybody was recommended, they go on oral hormone replacement therapy. Do you remember this thing?
Maybe you don't remember it, but people who were, there were some studies that came out in the early 20 aughts about that. If women went on hormone replacement therapy, which before was given, because it was thought that maybe people would live forever if they were on it, it actually increased the risk of breast cancer. And so when people were on the therapy, breast cancer risk went up. When they went off of it, breast cancer risk went down.
It just turns out now with all of our therapies and with the screening. Right. And finding breast cancers earlier, fewer women are dying from breast cancer. The rate per 100,000 women has really dropped and is continuing to drop.
[00:42:37] Speaker B: I'd like to touch on mammograms sometimes. That can be kind of controversial to some people. It feels like people have 3D mammograms or the 2D mammograms. I'm wondering, how do you decide what kind of mammogram you get? And is it worth getting that scare because three Ds obviously see much more.
Is that kind of gone away, or are they pushing more towards always having a 3D? How does that work?
[00:43:07] Speaker A: Well, so let's kind of drill down a little bit on this stuff.
Before there were 3D mammograms, you have a two dimensional mammogram.
And guess what? The risk if you had a two dimensional mammogram once a year for ten years.
What do you think the risk was of getting called back to do more scans and maybe even a biopsy?
It was 60%.
So then 3D mammograms came out and it's very clear that there are fewer false positives, fewer false negatives, fewer people are having to have callbacks. So to my view, there is no question in my mind everybody should get 3D mammograms.
[00:43:53] Speaker B: Why don't they just do 3D mammograms then?
[00:43:56] Speaker A: Well, they should. That's the recommendation by us.
[00:43:59] Speaker B: I understand, but why even have the 2D machines out there?
[00:44:04] Speaker A: Because they're already out there. Who knows? This is about healthcare and economics.
Gets me very upset.
[00:44:12] Speaker B: So I've touched a hot button.
[00:44:14] Speaker A: It did. Right. Because clearly, if it is not in anybody's best interest to get a 2D mammogram, since there's such a high chance of getting called back for something that's not cancer, 3D mammograms, that chance has really dropped significantly.
And so that, that's why everybody should get a 3D mammogram.
And in the clinic, I think that people should continue to get mammograms as long as we think they're going to be alive five years from now.
[00:44:46] Speaker B: When you do mastectomies, not everyone, I think, but I often hear people about doing reconstruction.
So then how are you checked for any, anything that might come back if you're reconstructing?
[00:45:03] Speaker A: That's a very good question.
When breast cancers come back locally, either in the breast, if there's still a breast there, or in a reconstructed breast, it tends to happen in a way that you can examine and see it. So that's why we continue to do breast exams or chest wall exams on people who've had mastectomies.
It tends to come back in a way that's palpable. It looks a little bit like a zit, but there's no head on it. It's a little small red thing that's characteristic and it's firm, but it's not painful. And we look for these things because if we find them, if we find a relapse on the chest wall, you can still cure people by just removing that relapse there.
[00:45:46] Speaker B: Got you.
And can you still do MRIs on reconstruction?
[00:45:53] Speaker A: Well, there's no reason to, unless something else is going on.
[00:45:56] Speaker B: If it gets into the lymph nodes.
[00:45:59] Speaker A: Yeah, same thing you do MRIs for breast cancer screening. Breast MRIs are useful for a surgeon to figure out what is the extensive surgery that person needs, and they're also useful in somebody who has a BRCA mutation or other kind of inherited predisposition to breast cancer. It's pretty clear that if you alternate MRIs with mammograms, you can find cancers earlier when they're more curable.
And finally, sometimes we go to MRIs when somebody has a mammogram and is negative and three weeks later they develop a breast cancer, you think, well, God, it had to be there three weeks earlier. Your mammogram didn't show it. So we don't trust a mammogram. So that's why you would do an MRI. But once somebody has had a mastectomy, there's no reason to do mammograms or MRIs on a reconstructed breast.
[00:47:02] Speaker B: What about the chest wall?
[00:47:05] Speaker A: Yeah, same thing. I mean, you can just examine.
[00:47:07] Speaker B: You can just examine it. Okay.
[00:47:09] Speaker A: You can just examine and you can see it.
[00:47:12] Speaker B: What is happening in the research field? Is there anything new? Is there anything that is just on the verge of coming out or just came out that they're experimenting with that could change the field of the breast cancer cure?
[00:47:30] Speaker A: Yes, there's stuff happening all the time, and it's all based on trying to understand the pathways that result in breast cancer growth. So the more that is understood about the pathways, the more we can kind of target certain things within the pathways to block breast cancer, which is why we get gene testing, not just on the person, but also on their cancer, to see what drives it. Immunotherapy.
Immunotherapy is we're trying to figure out how you can turn on the immune system to recognize other cancers or if there's other parts of the immune system that we need to goose a little bit to help with that. So, yeah, there's tons of new things coming down the pike all the time, but I do want you and your listeners to know that the vast majority of breast cancers in the early stage setting before it has spread, are cured with our current therapies.
[00:48:27] Speaker B: And what happens if it's spread?
[00:48:32] Speaker A: If it's spread in an obvious way on imaging, like if you see something in a bone or the liver or the lungs, and it is not curable, but if somebody has something you can't cure, what do you want for that person? Well, we want two things. That's what you want for anybody you feel close to. You want them to live as long as possible, and you also want them to have the highest quality of life. Quality of life, I'm sure, is very important to you and your listeners, everybody.
And so we can often help people whose cancers have spread have a very long life with a really good quality of life, particularly if they're luminal A or luminal B breast cancers, where you just go on hormonal therapy.
[00:49:15] Speaker B: And obviously there's tests or there's research going on all the time. And how do people get in, like, if they want to get into doing different testing and experimental stuff?
[00:49:33] Speaker A: That's a great question. So we try to get as many people on clinical trials as we can. So if somebody has a new diagnosis of breast cancer, they should ask their oncologist if there's any clinical trials for which they are eligible.
The National Cancer Institute has a website of every clinical trial going on in the country, so you could definitely find something.
But I was in practice for 20 years before I went to community practice, before I went to the university.
And sometimes it gets a little busy in community practice. So people don't talk about research as much as they should. That's not always the case. You can still get involved in clinical research as somebody who goes to a medical oncologist in the community, but it's something that you really have to ask about.
[00:50:20] Speaker B: How much do you work at all with Mayo? Because Mayo is pretty renowned for what they do. The Mayo Clinic.
[00:50:31] Speaker A: Mayo.
Mayo. It's a condiment, right? I mean, I do, right?
[00:50:39] Speaker B: Right.
[00:50:40] Speaker A: Not really quite sure what that's.
Oh, the WFMC, the world famous Mayo Clinic. That's 90 miles south of us. Yes.
I work for breast cancer and prostate cancer, and all of us kind of know each other. And I'm very proud of the university's prograM. We don't send people to Mayo for a second opinion because we all have access to the same data and trials. We're always all at the same meetings. We like to work together, we like to collaborate on research projects, but we feel that we are the same kind of resource that Mayo is for Minnesotans.
But people can always go to Mayo. I think it's a wonderful place. I've been there. I have a show that I do. I've done that down there a number of times. I really like the people at Mayo, but we at the university feel that we're NCI designated cancer center, nationally known, and we are a good option for the people who need another opinion. But they can certainly go to Mayo, too. There's nothing wrong with that.
[00:51:51] Speaker B: And how do we compare with cancer centers around the country?
[00:51:56] Speaker A: I'm not quite sure.
[00:51:59] Speaker B: How do we compare with. I presume that we're up near the top of.
[00:52:04] Speaker A: We are. Yeah. I mean, we are an NCI designated comprehensive cancer center. We just applied for our grant, and it was renewed by the National Institutes of Health with glowing reviews.
So I'm proud to work there.
It's got a national reputation. We have nationally known wonderful medical oncologists, for example, like Anne Blaise and Doug, he and the breast cancer side, Emmanuel and Tona, raucous on the prostate cancer side.
It is a great option for the people in the state of Minnesota if they want to get another opinion regarding their care or get their care with us.
[00:52:48] Speaker B: Well, you've given us a lot of information. I really appreciate it. Is there anything.
[00:52:52] Speaker A: I couldn't shut up. I really could not shut up.
It's a problem. I should go on medication.
[00:52:58] Speaker B: Charlene, is there anything you'd like to ask?
I'm just blown away. I can't even think of another question. It's been a very good interview.
[00:53:08] Speaker A: Well, thank you. Well, it's a real privilege to do this, and thank you for asking me.
[00:53:14] Speaker B: You've been listening to disability and progress. The views expressed on the show are not necessarily those of KFEi or export of directors. My name is Sam. I've been the host of the show. Charlene Dahl is my Research woman. Miguel Vargas was my engineer today, Erin is my podcaster. We have been speaking with Dr. Stuart Bloom about breast cancer, and may all of you who are suffering with this cancer have the best outcome possible.
This is KFAI, 90.3 FM, Minneapolis, and kFai.org. Remember, you can email us at
[email protected] thanks so much for listening. Goodbye.
