Jo’s hope for future generations – we get smarter, more effective and more successful in breast cancer diagnosis and treatment

Jo was diagnosed with Grade 2, Stage 2 hormone receptor-positive, and HER2 positive invasive ductal breast cancer. She shares her thoughts about her breast cancer journey and being part of the POSNOC  trial;

How old were you when you were first diagnosed with breast cancer and what went through your mind? 

I was diagnosed just one week before my 54th birthday. My mum was diagnosed with her breast cancer on my 40th birthday and that always upset her, so I was firstly sad that I was going to have to tell her I now had cancer too, right around my birthday again. Timing wise I was not impressed at all.

Other than that, I was not surprised strangely; it all was a bit surreal. I have had some pretty crazy things happen in my life so I on one level just thought here we go, what’s this ride going to be like.

Do you have a family history of breast cancer?

It turns out my family has had four generations we know for certain that have had breast cancer on both sides of my mum’s family. Weirdly all of the instances of cancer in the women in my family has been different, so no genetic link specifically. 

But given my uncle and father both died of bowel cancer and my remaining uncle is a bowel cancer survivor I was ok with getting breast cancer, as that to my way of thinking was an easier cancer to deal with. Mammograms had always been easier to do, and way less drama than colonoscopies, was my logic. 

Why did you participate in a clinical trial?

I have four nieces, and they have had both their aunts and grandmothers and great grandmothers on both sides of their family get breast cancer. How could I not participate in something that could help them?

I also have been lucky to have had positive experiences with other medical events in my life where I both contributed to and benefited from research by my medical team at that time. It just made sense to say yes.

Why is breast cancer research so important to you?

When you get cancer you suddenly discover so many women around you have been where you are about to go. Sadly you also find yourself discovering more are following. My treatment and experience was all the more successful because of the research done by and assisted by other women in my situation. So every bit you can do helps. Collectively it can be a pretty powerful thing. I like that being part of something bigger aspect.

What was it like being on the trial?

Comforting. Knowing I would get that extra bit of attention. 

Satisfying. Knowing my experience and data is adding to a body of research that will ultimately benefit others.

Reassuring. By participating in the POSNOC trial gets the numbers it needs to make a difference quicker. 

What is your hope for future generations?

That we get smarter, more effective and more successful in all aspects of breast cancer identification and treatment. 

ANOTHER BREAKTHROUGH FOR RESEARCHERS IN BREAST CANCER TREATMENT – MONARCHE TRIAL INTERIM ANALYSIS

A recent interim analysis of the international “monarchE” trial has shown a significant decrease in the risk of breast cancer recurrence or death for those taking the drug Abemaciclib in combination with standard endocrine therapy, compared to standard adjuvant endocrine therapy alone.

The Waikato has been a centre for the monarchE trial since 2018. This clinical trial is investigating whether the oral drug Abemaciclib can improve the outcomes in women or men with high-risk hormone receptor-positive (HR+) and human epidermal receptor 2 negative (HER2-) early breast cancer. Abemaciclib stops the production of proteins in the body called CDK4 and CDK6, which are responsible for promoting cell growth. It has been shown to have antitumor activity and significantly reduce tumour growth, including breast cancer. Abemacicilib is taken twice daily in tablet form over a two year period.

90 percent of all breast cancer is diagnosed at an early stage and 70 percent of all breast cancers are HR+, HER2-, the most common subtype. Despite the progress in the treatment of breast cancer, approximately 30 percent of people diagnosed with HR+, HER2- early breast cancer are at risk of their cancer returning, potentially to incurable metastatic disease (spread of cancer to other parts of the body). This risk of recurrence increases based on certain  features such as breast cancer that has spread to the lymph nodes in the armpit, a larger tumour and a high grade (more aggressive) tumour .

“There has been a great need to improve endocrine therapy for breast cancer patients who are at high risk of disease recurrence.  The monarcE trial was specifically designed for patients with breast cancer at high risk for returning. Through the monarchE trial 5,637 people around the world have taken part in this research which has demonstrated positive results,” shares Waikato monarchE trial coordinator and research nurse Jenni Scarlet.  “If we can prevent women and men diagnosed with high-risk early-stage breast cancer from developing metastatic or incurable breast cancer then this would mean many lives saved”. The monarchE trial is headed in the Waikato by Medical Oncologist and WBCRT Trustee Dr Marion Kuper-Hommel.

In the Waikato, the Waikato Breast Cancer Research Trust has enabled six patients the opportunity to participate in the monarchE trial. The trial will now continue through to the completion date, estimated for June 2027. All participants will be followed to assess overall survival and other outcomes.

Research over the past 20 years continues to answer questions about reducing treatment to the axilla

The status of the axillary or armpit lymph nodes remains the most important indicator of outcome for women diagnosed with breast cancer, and helps predict the need for further treatment (e.g. chemo or radiotherapy). Traditionally, axillary node status has been determined by the removal of all of the nodes (called axillary clearance or axillary node dissection).  This operation may lead to arm swelling (lymphoedema), pain, some abnormal skin sensation, and shoulder stiffness.  Over the past 20 years the WBCRT has enabled the introduction of a reduced surgery to the armpit called “sentinel node biopsy”. Sentinel node biopsy involves surgical removal of the lymph nodes most closely related to the breast cancer (usually 2-3 lymph nodes).

Since 2001, Waikato Breast Surgeons and researchers have participated in a learning phase of sentinel node biopsy, followed by four international clinical trials introducing sentinel node biopsy surgery for different types of breast cancer.

The sentinel node biopsy trials have been part of the journey of reducing the amount of breast cancer surgery. In the 1970s it was believed that all women with breast cancer needed a mastectomy, and nowadays most women don’t need a mastectomy, and breast-conserving surgery is performed in a majority of cases. Prior to the early 2000s, all women underwent axillary clearance.

The most recent sentinel node trial is the “ POsitive Sentinel NOde: adjuvant therapy alone versus adjuvant therapy plus Clearance or axillary radiotherapy” or “POSNOC” trial. This is a UK led international trial, which is coordinated in Australia and New Zealand by Breast Cancer Trials ANZ.

At the moment, it is usual for women with a small amount of cancer spread to 1 or 2 sentinel lymph nodes to have further treatment (axillary clearance or axillary radiotherapy). The POSNOC clinical trial is investigating whether some of these women may be able to avoid treatment to the armpit, and, as a result, avoid the side effects of this treatment as well as how this treatment affects a woman’s quality of life.

It is currently believed that women with more than a tiny amount of cancer in the sentinel node need to have the other lymph nodes removed (axillary clearance). This may or may not be true, and this is the question that the POSNOC clinical trial will answer. Very often there is no cancer seen in the other armpit lymph nodes when removed. So those women get the short and long term side effects of the axillary treatment for no benefit.

We now know that additional therapies (e.g. hormonal therapy and chemotherapy) are very good at preventing the cancer from coming back, so additional treatment to the axilla (armpit) may no longer be needed. Previous research suggests that axillary treatment may not change the risk of the cancer coming back in the armpit or anywhere else. However, more research is needed to give a clear answer.

If we can prove that less axillary treatment is just as safe as doing more treatment, this will be a great outcome for women diagnosed in the future.

Recruitment for this UK led trial is planned to complete in mid-2021. We acknowledge the Waikato and other NZ women who have had the courage to participate in this trial.

Good news for postmenopausal women with a high risk of breast cancer

As an oncology nurse Lorrie Kurth has seen the effects of breast cancer first-hand.

Lorrie has a high risk of breast cancer. She has lost her grandmother, her mother and a cousin to the disease, another cousin has had breast cancer and so has an aunt.

Ten years ago, Lorrie joined the anastrozole medical prevention trial to help researchers find a way to prevent the disease.

“It’s was such a good opportunity to help other generations of my family and other families”.

At the time of enrolling in the trial, Lorrie knew that it could take 10 years for the trial to determine whether the drug would help prevent breast cancer.

Ten years have now passed and the long-term results of using anastrozole for breast cancer prevention were published recently and its good news for wāhine like Lorrie that are at high risk of breast cancer and ductal carcinoma in situ (DCIS).

The results show that anastrozole maintains a preventative effect for postmenopausal women at high risk of breast cancer for at least 12 years.

Anastrozole inhibits the production of oestrogen in postmenopausal women and has been used for several years now in the treatment of postmenopausal women with oestrogen receptor-positive breast cancer.

The use of anastrozole, which is part of a class of drugs called aromatase inhibitors, is more effective than tamoxifen in women who have already had breast cancer.

This research shows that anastrozole is a safe drug in the long-term and provides women with greater options when it comes to managing their risk. Other options include regular breast screening, preventative surgery and a healthy lifestyle.  

Lorrie has not been diagnosed with breast cancer, she is in good health and has never dwelled on her higher chances of getting the disease. “It’s not something I spend a lot of time thinking about. I work on the theory that if it happens, I’ll deal with it then. “I have had excellent surveillance throughout the trial, particularly with my family history, and this has been very comforting.”

Lorrie is philosophical about cancer and death because of her years of working as an oncology nurse. “I’ve learned from looking after people with cancer that you have to live every day and make the most of that day.”

Research continues to answer questions about sentinel lymph node biopsy

Whether or not breast cancer has spread to the axillary or armpit lymph nodes, remains an important indicator of outcome for women/wāhine with breast cancer, and may help predict the need for further treatment (e.g. chemotherapy or radiotherapy). Historically axillary node status has been determined by removal of most of the nodes (axillary clearance).  This operation may lead to arm swelling (lymphoedema), pain, some abnormal skin sensation or shoulder stiffness.

Waikato Hospital surgeons and researchers introduced “sentinel node biopsy” to breast cancer surgery in 2002. Sentinel node biopsy involves the removal of only a small number of lymph nodes most closely related to the breast cancer.

The Waikato is now a centre for a fourth international sentinel node biopsy trial. It is important we carefully evaluate the benefits and risks of introducing this lesser surgery to the axilla for women/wāhine with different types of breast cancer. Helen is a participant on the “Sentinel Node biopsy versus Axillary Clearance Part 2 (SNAC 2) trial, she recently shared with us her journey.

As the daughter of a pharmacist and a nurse, being an occupational therapist myself and married to a medical man, particpating in a clinical trial seemed sensible

“It has been difficult to remember many details about this story as it began 10 years ago, and my mind has proven to have the ability to forget the actual pain and discomfort.

I had had a history of cysts over the years so when a routine mammogram indicated I should have an ultrasound; I assumed more cysts. I was surprised to be told I had breast cancer and disbelief was my initial reaction as I felt remarkably fit and healthy and well! My next reaction was “Tell me the plan to get rid of it”. The label for my breast cancer was multifocal grade 2 invasive lobular carcinoma and the advised plan was to have a total mastectomy with reconstruction. ‘In for a dime, in for a dollar’ – get it all over and done with in one hit was my reasoning.

With this plan timetabled, my surgeon, Ian Campbell, asked if I would participate in a clinical trial. As the daughter of a pharmacist and a nurse, being an occupational therapist myself and married to a medical man, this seemed sensible. I reasoned that it may help with future treatments and improve life expectancy for others. It was SNAC 2 trial, Sentinel Node biopsy versus Axillary Clearance.

Needless to say, I ascertained there was no additional risk to myself, only a couple of extra appointments and another ultrasound with dye injected to trace which lymph nodes were feeding / draining the three tumours.

My surgery proceeded as expected but then came the news that one lymph node had cancer cells and with that news, another date with the surgeon was organised. Following this I was discharged with a drain in place which the district nurse encouraged me to keep until there was no more fluid to drain. I have been lucky enough to escape any issue with lymphoedema.

For some weird reason I had thought that the surgeries would suffice to beat this cancer but no … chemotherapy, followed by radiation, gave me better survival stats so again – ‘in for a dime in for a dollar’. I took all the drugs to combat the side effects of chemo, wore my wig and managed.  The radiation was a chore and I remember feeling weary towards the end. Now, 10 years later, the whole experience is a bit of a blur, but I know it irrevocably changed my life and furnished me with the resilience and understanding to dual with further life events.

I know that I would not have come to this place without the comfort and kindness of friends and family.”

Clinical trial “ Examining Personalised Radiation Therapy (EXPERT) for low-risk early breast cancer

The current standard of care for women with early breast cancer is radiation therapy after breast conserving surgery to reduce risk of recurrence and improve survival. However, breast cancer is a complex disease and the absolute benefit of radiation therapy in individual patients varies substantially. 

The EXPERT clinical trial is investigating whether a laboratory test called a genomic assay can help doctors select out women with low risk breast cancer, who may be able to avoid radiotherapy and its associated side effects.This research aims to improve personalised use of radiation therapy in early breast cancer patients, according to individual risk of local recurrence.

Waikato Hospital is a centre for this international clinical trial coordinated by Breast Cancer Trials Australian & New Zealand. Other centres in New Zealand are Palmerston North, Wellington and Christchurch Hospitals.

To learn more visit: https://www.breastcancertrials.org.au/current-clinical-trials/expert

Waikato led research, highlights the importance of early detection

Data from the Waikato and Auckland Breast Cancer Registers on women aged 45-69 years and diagnosed with invasive breast cancer between January 2005 and May 2013 was analysed by researchers from the Universities of Waikato, Otago and Auckland and the Waikato DHB. The research team was led by Professor Ross Lawrenson (Waikato Medical Research Centre) and included Associate Professor Ian Campbell (WBCRT Chair).

Results from this research were published in the Journal of Medical Screening in March 2019,and concluded that– breast cancers detected through breast screening are diagnosed at an earlier stage, showed a greater proportion of subtypes,with better outcomes.

For screen-detected breast cancer, survival between different ethnic groups was similar.

Variations in survival for Māori and Pacific women are only found in women with non-screen detected breast cancer. One of the main reasons that outcomes of breast cancer in Māori and Pacific women are poor compared with NZ European women, is the late stage at diagnosis.

Remind the wāhine/women you love, to book their screening mammogram.

To book a mammogram today, phone 0800  270 200 (Breast Screen Aotearoa).

WAIKATO CLINICAL TRIAL OF A NEW SURGICAL TECHNIQUE FOR THE TREATMENT OF BREAST CANCER RELATED ARM LYMPHOEDEMA – SEEKING PARTICIPANTS

Waikato researchers are now seeking participants with breast cancer related lymphoedema for a larger clinical trial to determine whether lymph node grafting produces a greater reduction in lymphoedema volume and improved quality of life, compared with standard treatment.

Lymphoedema is a condition experienced by 10-20% of people who undergo axillary lymph node dissection – an operation often performed as part of breast cancer surgery.  The current standard of care for lymphoedema is conservative management which includes self-administered massage, therapeutic exercise, and use of a compression garment.

When conservative management does not help enough, surgery can be considered.  There is some evidence to suggest that transferring lymph nodes from elsewhere in the body to the affected limb can help to reduce the size of the affected arm.

A new, surgical technique, called lymph node grafting, has been developed and tested in a pilot study in the Waikato. The results of the pilot study demonstrated that lymph node grafting showed promise as a treatment for moderately severe treatment-resistant lymphedema.

Local researchers need further evidence to be certain that this technique is safe and effective, and to standardise and develop the lymph node grafting technique further.  In both the pilot study, and to date in the clinical trial there have been some patients who have experienced a reduction in lymphoedema, but also some who have not.  We need to learn more about why this is the case. We also need to ensure that lymph node grafting doesn’t make lymphoedema of the arm worse, and doesn’t lead to lymphoedema of the donor leg.

Participants who agree to participate will be randomly assigned to either:

  • the control group (standard care): Will receive standard lymphoedema therapy alone. This includes self-administered massage, therapeutic exercise, use of a compression sleeve and skin/nail care; OR
  • the intervention group: Will undergo lymph node grafting surgery as well as standard lymphoedema therapy.

Waikato Plastic Surgeon Mr Winston McEwan who has developed the lymph node grafting technique, is heading this trial.

For more information, or if you or anyone you know  may be interested in this research, please contact Heather Flay, Research Nurse on telephone 07 8398726 Ext 97960 or email Heather.Flay@waikatodhb.health.nz; or Jenni Scarlet, Research Nurse on phone 07 8398726 Ext 97916 or email Jenni.Scarlet@waikatodhb.health.nz

A few minutes is all it takes – a mammogram can save your life

WBCRT researchers were part of a team working with Professor Ross Lawrenson (Professor of Population Health, University of Waikato) on a Health Research Council funded research project investigating the outcomes for Māori and Pacific women diagnosed with breast cancer.

Information from over 12,000 women with newly diagnosed breast cancer from the Waikato and Auckland Breast Cancer Registers was analysed.

Results showed that women with early screen detected cancers have a high chance of cure with 93% of these women alive at 10 years after diagnosis. The outcomes for women with screen detected cancers, are the same regardless of ethnicity, or socioeconomic status.

On the other hand, Māori women presenting outside of the breast screening program with symptomatic cancers e.g. a breast lump, were more than twice as likely to die from their cancer than women of European ethnicity, and Pasifika women fared even worse. Women from poorer socioeconomic backgrounds also did significantly worse if diagnosed outside the screening program.

To save lives we need to focus on early detection and presentation to healthcare services for more women. Improving access to breast screening has the potential to significantly improve the situation for those women most at risk, and for all women.

Regular mammography screening works best for early detection of breast cancer, less radical treatments and better survival outcomes.