Q&A with UCLA Health’s Dr. Anita Kaul
Breast cancer affects thousands of women and men each year, with an estimated 252,710 new cases of invasive breast cancer occurring among U.S. women in 2017, and 40,610 breast cancer deaths, according to the American Cancer Society. Thanks to advances in medicine and continued research, more and more women are beating breast cancer.
Drawing from more than 20 years of clinical practice, including serving as Cancer Committee Chief at Los Robles Hospital & Medical Center, Simi Valley Hospital and Providence Saint Joseph Medical Center, Dr. Anita Kaul, UCLA Health breast cancer specialist in Westlake Village, shares insights and updates about breast cancer.
Q. What advice or reassurance do you give a woman who receives a breast cancer diagnosis?
A. It is very important for women to know that breast cancer is a very common diagnosis, and most women survive their breast cancer. But the No. 1 cause of death in breast-cancer survivors is actually heart disease, not recurrence. Therefore, we need to take care of the cancer, but we also need to take care of the patient. That means maintaining a healthy lifestyle with good nutrition and exercise, and managing risks like diabetes, high blood pressure and cholesterol.
Q. How is treatment for breast cancer changing?
A. We used to define cancers according to the part of the body where they originated, but as we gained a better understanding of cancer biology, it became clear that no cancer is just one disease. Our only tools were surgery, chemotherapy and radiation, but today we try to discover and target the mechanisms driving the origin and development of a cancer.
In breast cancer, this leads us to three general categories: hormone receptor-positive cancers, HER2/neu-positive cancers and triple-negative cancers. Understanding the drivers of each disease gives us the opportunity to develop personalized therapies targeting those mechanisms.
Researchers around the world are working hard to develop new strategies to fight breast cancer through immunotherapy, the discovery of new gene targets, the development of “smart bombs” that attack cancer cells and minimize treatment side effects, and other technologies.
UCLA physician-researchers and others are currently exploring several frontiers. One research area that looks promising is the identification of androgen receptors, which have been found on all types of breast cancers—even a sizable number of triple-negative cancers, which have been difficult to target. Studies are now underway to determine the potential clinical benefit of targeting these androgen hormone receptors, and there have been some promising results.
Beyond this basic level of personalization, we sometimes do genetic profiling of a tumor in advanced cases or when a treatment, like anti-estrogen therapy, stops working. This may be done by analyzing new tumor biopsies or looking at circulating tumor cells in blood samples. We want to understand the mutations occurring in the tumor and their implications. This gives us information on how to adjust the treatment to make the anti-cancer response last longer.
Q. With this ongoing research, what do you think breast cancer treatment will look like in five years?
A. I think we are going to see even more targets emerging for precision-medicine techniques, which will translate into better, more effective treatments, longer survival and fewer side effects. Specifically, I think we’ll see significant progress in the treatment of triple-negative breast cancer, where we’re starting to see light. Immunotherapy seems to be effective in many triple-negative breast cancers and may expand to others in combination therapies. There are new, targeted drugs becoming available for different types of breast cancer, and I’m excited about the possibility of androgen receptors as another possible target to block tumor growth.
Q. In the past year, there has been discussion about over-testing and over-treatment of early-stage breast cancer. How are treatment decisions made?
A. National testing and treatment guidelines are formulated by analyzing statistics on lives saved, costs and other factors like negative impact from tests or treatment, with the goal of ensuring that patients receive the care they need but are not receiving unnecessary tests or treatments with no proven value. For example, there is no proven role for what we call tumor marker blood tests or whole body scans for follow-up evaluation of early stage breast cancer. As a woman and a doctor, I understand a patient’s desire that we provide all appropriate treatment and testing, and we discuss options together along with the pros and cons of such interventions.
Keep in mind that any test can produce false-positive and false-negative results. Tumor marker tests, which are appropriate in some cases, are chemical tests done on a blood sample, and we’re realizing that medications and even supplements can influence the results. For example, recent reports showed that biotin, a common supplement that many women take, can affect some tumor marker test results. This doesn’t mean it changes the cancer, but it can change the test results. Therefore, whenever a test comes back abnormal, we need to take a breath and recheck it. We do not jump to conclusions just because one test is a little bit off, and we only make treatment decisions if we do several tests confirming that there is a real problem.
Q. Survival statistics for metastatic, or stage 4, breast cancer, have remained flat for many years. Are any new treatments in the pipeline?
A. There are many exciting treatments coming along, but one issue about advanced breast cancer is that not all women throughout the country receive the same level of treatment, whether because of socioeconomic situations, location or other factors. We want all women to have access to high-quality care, and one way we can accomplish that is to provide access to clinical trials, which are available through our clinics.
We are seeing success in treating advanced breast cancers, but overall survival data takes some time to show up. For estrogen-positive tumors, the addition of new drugs is allowing women to stay on hormone-directed therapies much longer before needing to start chemotherapy. For HER2neu positive tumors, new, targeted therapies and new drugs that act like “smart bombs” are delivering Herceptin and a chemotherapy drug directly into cancer cells, increasing survival and reducing side effects. Triple-negative cancer has been more challenging, but immunotherapy looks like it will be helpful. Additionally, new, targeted drugs are on the horizon, and innovative chemotherapy delivery mechanisms are being developed. I think androgen receptors may provide another important mechanism for treating many breast cancers.
Q. What are the latest guidelines on how often a woman should have a mammogram?
A. There has been a lot of confusion, but we’re learning that there is no one-size-fits-all recommendation. For the general population, screenings usually are done every one or two years, but some women need more and others need less. Our goal is to do the right screening at the right frequency for the right kind of patient.
Women who carry a cancer-related gene like BRCA, those with a significant family history of breast cancer and those with a previous biopsy finding of precancerous changes are among patients we consider to be high-risk and need more frequent and in-depth screening. In our High Risk Breast Clinic and at our other clinic locations, we tailor screening and prevention strategies based on risk profile.
Although mammography is the best routine screening technology, it has limitations because some cancers are very difficult to see on mammograms, and reading the mammogram of a woman with dense breasts is like looking through a dirty glass.
Therefore, for high-risk patients, we regularly use ultrasound, 3D mammography, MRIs and other tools for early detection.
One important factor is for women to be aware of their breast density. A common misunderstanding is about the relation to size of breast, but breast size has nothing to do with density. About 36 states now have legislation requiring mammogram reports to include notification of breast density so that patients and their physicians will be aware of higher risk and decreased sensitivity of mammograms in patients with dense breasts. Mammograms are still effective tools, but there needs to be additional testing in these patients.
Q. What are you most hopeful about in the field of breast cancer treatment and survival?
A. I’m most hopeful that we’ll see real progress in all breast cancers, but especially those that have been very challenging, and in advanced metastatic disease. Precisely targeted therapies and new, “smart” chemotherapy agents that are delivered inside cancer cells will not only keep patients alive longer, but also maintain their quality of life.