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April 23, 2020 01:30pm
By Stephen M. Schleicher, MD, MBA
Although groundbreaking research findings are met with much fanfare during large medical conferences, their practical application to the community oncology clinic may not always be immediately clear.
Patrick I. Borgen, MD
Although groundbreaking research findings are met with much fanfare during large medical conferences, their practical application to the community oncology clinic may not always be immediately clear. Ways of integrating findings into a physician’s practice are not covered, even though presentations feature some of the high­est-level clinical trials, retrospective reviews, and labo­ratory research. The37th AnnualMiami Breast Cancer Conference® is not the only big conference covering breast cancer research, but it fills an important gap that others do not.
Many attendees of the Miami Breast Cancer Confer­ence® find it complementary to the San Antonio Breast Cancer Symposium, according toPatrick I. Borgen, MD, program cochair of the Miami conference.
“Our faculty, many of whom have presented their research at the San Antonio conference, come to Miami research at the San Antonio conference, come to Miami to say, ‘Here’s how you use this clinically. Here’s how we apply the research lessons learned at meetings like San Antonio. Here’s what we believe best practice are for applying this to you day-to-day practice,” said Borgen, who is chair of the Department of Surgery at Maimon­ides Medical Center and director of the breast cancer program at Maimonides Cancer Center in Brooklyn, New York. “And I think that’s a unique niche that [the Miami Breast Cancer Conference®] fills.”
Borgen spoke about important breast cancer advances and the overall goal of the meeting, which is hosted by Physicians’ Education Resource®, LLC, in Florida, from March 5 to 8, 2020, in an interview withTargeted Therapies in Oncology.
“[The conference will offer] clinically applicable information designed for the practicing surgeon, oncol­ogist, radiation oncologist, radiologist, and pathologist who is in the trenches, diagnosing and treating breast cancer every day,” Borgen said.
In a fortuitous turn, during last year’s Miami Breast Cancer Conference®, the FDA approved atezolizumab (Tecentriq) for adult patients with PD-L1positive, unresectable locally advanced or metastatic triple-negative breast cancer.1This was the first immunother­apy approved for treating patients with breast cancer, and the oncology community has since learned more about this kind of treatment, which Borgen said will be featured at the conference in 2020.
T-DM1 (ado-trastuzumab emtansine; Kadcyla), an antibody-drug conjugate, has also received approval since last year’s conference.2It is used as neoadjuvant therapy when treating patients with HER2-positive breast cancer who have residual tumor burden. “We continue to refine our understanding and treatment of HER2-positive breast cancers, said Borgen.
We’ve also seen at least 3 commercially available cell cycle checkpoint inhibitors in the estrogen receptor positive, HER2-negative space,” Borgen continued. “These drugs have set a new standard of care, partic­ularly in the metastatic setting…, [and] the strong implication is that breast cancer is certainly more complicated to treat than at any [other] time in history.”
Some 10 to 15 years ago, clinicians treated breast cancer as though it was a single disease instead of a family of diseases, according to Borgen. Now that there is a “deeper understanding” of breast cancer and its subtypes, he said, targeted treatments have emerged.
In the past, patients would receive surgery first, followed by chemotherapy, then radiation, and lastly hormone treatment. Today that sequence starts with neoadjuvant chemotherapy or a neoadjuvant estro­gen blockade, “so something as fundamental as the sequence of the treatments has changed dra­matically over the past decade,” said Borgen.
For instance, targeted immunotherapy agents such as trastuzumab (Herceptin), pertuzumab (Perjeta), and T-DM1; the checkpoint inhibitor atezolizumab; and PARP inhibitors such as olaparib (Lynparza) and talazoparib (Talzenna) are effective in patients with metastatic breast cancer who also have aBRCA1orBRCA2patho­genic mutation. Borgen said that almost all patients with metastatic breast cancer are now routinely tested for these mutations.
“It’s a more complicated horizon,” Borgen said. “But the glass is clearly half full because patients are doing better than they’ve ever done before. Survival rates continue to increase, and that increase is accelerating. So, the future is incredibly bright.”
Borgen believes the most exciting research coming out for breast cancer is in the neoadjuvant space, like neoadjuvant endocrine and hormonal therapy and chemotherapy. Because of these ther­apies, clinicians can often lessen the magnitude, disfigurement, and disability related to surgery.
“We’re doing smaller yet more sophisticated surgeries because patients are receiving medi­cal therapy first,” Borgen explained.
Because more emphasis is on the medical therapies being used to treat patients with breast cancer, the way the Miami Breast Cancer Conference® delivers that message has evolved over time. In the 1980s, when the meeting was founded, mastectomy was the most common surgery for patients. Although estrogen block­ade with tamoxifen was available, it was not widely used, so the focus of the meeting was almost completely surgical.
“If you fast-forward to today35 years later— our audience is still about 60% surgeons, but the other 40% is vitally important and rounds out the team because today it’s impossible to treat this disease without a true multimodal approach,” Borgen said. “…And I think the Miami conference is unique in that it is truly multidisciplinary.”
At the conference, Borgen will present twice; the first presentation will be at the ple­nary session on Friday, March 6. His research focuses on patients with breast cancer who had late diagnoses, some with a series of imaging studies, to show a “natural history of untreated breast cancer in the modern era with modern diet and modern stresses,” he explained. His presentation will look at the growth of breast cancer over the course of years, showing that it is “completely impossible” to predict its growth rate. In the data set presented, all the patients’ tumors were ER-positive and HER2-negative.
“They should be a homogenous population, but what we show is how breast cancers actual­ly grow in a random, scattershot fashion,” Bor­gen stated. “This has a lot of implications. For example, in the medical-legal world, [if there is an issue with the diagnosis], the parties in the action will make bold statements about how big the tumor might have been or how big it was a year or two ago. This falls under the head of what’s called tumor doubling time, and what we show in this paper is that it’s almost impossible to predict a tumor doubling time.”
The second presentation focuses on Borgen’s work in eliminating opioids from breast cancer surgery. When Borgen moved from Memorial Sloan Kettering Cancer Center to Maimonides Cancer Center, he learned the surrounding neighborhood had an opioid problem, made apparent in the emergency department daily.
“A study showed that four-fifths of those addicts and victims of overdose started with an [physician]-prescribed narcotic, so about 5 years ago, we got heavily involved in trying to reverse this,” Borgen said.
Borgen and his colleagues have followed a mul­timodal analgesia plan to treat over 1000 consecutive patients who were getting a lumpectomy or mastectomy without reconstruction. This means that all their patients were discharged without a narcotic prescription, a model he hopes can be adopted on a national level.
In addition to his presentations, one of the sessions Borgen thinks is important centers on how to deliver bad news to patients, which has become more relevant as the diagnosis of breast cancer has evolved. Borgen explained that because the oncology community has a deeper understanding of breast cancerand the options of what the patient’s diagnosis could be as well as the more wide-ranging effects on a patient’s life—delivering the news to a patient has become more challenging.
To deal with this issue, last year’s conference included a first-time session on the discipline. The audience chose a topic and a faculty mem­ber, and that faculty member broke the bad news to an actress pretending to be the patient.
“Then the audience critiqued what worked, what didn’t work, what words were powerful, what words you should avoid, and what the style was,” said Borgen. “And I think the art of breaking bad news is unbelievably important, especially to our fellows and trainees.”
This year’s presentation, named the “Exigent Matters Workshop,” will be held on Sunday, March 8.
In short, the primary treatments for patients with breast cancer have changed in the past months and attending the Miami Breast Cancer Conference® will help physicians apply these important therapies in their practices.