This week on Real Pink we are hosting daily conversations about breast cancer that hides in the shadows: metastatic breast cancer (MBC).
In the US alone, MBC is expected to kill 42,000 people. This special episode, featuring Kelly Shanahan, is part of National Breast Cancer Awareness Month.
In 2008, Kelly Shanahan had everything going for her: a graduate of Bryn Mawr College and the University of Virginia School of Medicine, she had a busy and successful ob-gyn practice in South Lake Tahoe, CA; a precocious 9 year old daughter; and a well used passport from traveling all over the world with her family to attend conferences, with a liberal dose of vacation on the side. When she was diagnosed with stage IIB breast cancer in April, she considered it a mere bump in the road; after all, she returned to work two weeks after her bilateral mastectomy and continued to work all through the four months of chemo.
And for five years, breast cancer was an aside, something to put in the past medical history section of forms. Even when she developed sudden back pain, Kelly never thought it could be breast cancer rearing its ugly head – a pulled muscle, a herniated disc maybe, but not what it turned out to be: metastatic breast cancer in virtually every bone in her body, with a fractured vertebrae and an about to break left femur. Kelly was diagnosed on her 53rd birthday.
Kelly has been extremely lucky, for after an unconventional 14 month course of combination IV chemo and zometa, followed by a more conventional aromatase inhibitor, she has remained NEAD – No Evidence of Active Disease — since April 2014. Neuropathy from the chemo did cost her her career, but she has found a new purpose in advocacy. Kelly is a volunteer and grant reviewer for METAvivor; a member of the Metastatic Breast Cancer Alliance; an advisor to Metastatic Breast Cancer Canada; a member of the Komen Advocate Advisory Taskforce and Metastatic Breast Cancer Advisory Committee; and a consumer reviewer for the Department of Defense Breast Cancer Research Program. She says she will fight for more research funding for the already metastasized patient until her dying breath. Her current goals are to get five more stamps in her passport; celebrate her 25th wedding anniversary in January 2020 at The French Laundry; and to see her daughter graduate from college in May 2020. If she makes those goals, she’ll come up with another three!
Kelly Shanahan is a mother, a wife, a daughter, a doctor, a woman LIVING with metastatic breast cancer.
00:00 Metastatic breast cancer is the most advanced stage of breast cancer and the deadliest form of breast cancer accounting for the vast majority of the 42,000 deaths per year in the United States alone. Metastatic breast cancer has spread beyond the breast most often to the bones, lungs, liver, or brain. Most incidents of metastatic breast cancer, 94%, are the result of breast cancer recurring after a person has previously been diagnosed with breast cancer and completed treatment for early stage breast cancer, there is no cure for metastatic breast cancer, although treatments are allowing women and men with metastatic breast cancer to live longer than even five years ago. Treatments focus on extending life and improving quality of life. To talk to us more about the importance of research dedicated to conquering metastatic breast cancer. I have on the show today, Kelly Shanahan.
Adam: 00:53 Kelly, welcome to The Real Pink podcast. We’re glad to have you with us today. Can you tell us just a little bit about your story?
Kelly: 01:00 Alright, thank you, Adam. I’m really happy to be here. So my name asAdam said is Kelly Shanahan. I live at Lake Tahoe, California. I’m a wife, a mom, a daughter, a former doctor, a woman living with metastatic breast cancer, and my breast cancer story began back in 2008 when I had a routine mammogram and had a pretty obvious breast cancer that had been missed on a previous mammogram. I live in a small town, a resort community. I was a solo private practice, OBGYN with a nine year old daughter. I chose to have a bilateral mastectomy because we don’t have oncology in my town. We didn’t have a radiation oncologist. I mean, if you break a bone and you need an orthopedic surgeon, you’re good. But otherwise I had to drive and for me to have a lumpectomy and followed by radiation therapy would mean an hour and a half round trip drive every day, Monday through Friday for five minutes in the radiation machine.
New Speaker: 02:02 And as a solo practicing OBGYN, I couldn’t take that time away from my practice. So I chose to have a bilateral mastectomy. Remember my husband’s not in medicine, he’s a builder and I remember taking like the little, old dictaphone and recording “What’s the lymph node? What’s the [02:21 unclear] node?” And I said to my husband, hit play so that the surgeon can hear this. I went to San Francisco for my surgery and then hit record so you can record the answer. And I remember waking up in the recovery room after my mastectomy saying, what’s the node, what’s the node? And I had one positive lymph node, which I knew that I would have to have chemotherapy. So I had four months of pretty standard chemotherapy, went back and had my final reconstruction done and then really put breast cancer behind me. It was something that was to put it the past medical history section on forms.
New Speaker: 02:59 And I went on with my life, but five years later I developed some back pain and I thought for sure I was five years out. I was cured at that five year mark you’re cured. And slightly after that I developed some back pain. I thought I had pulled a muscle, it didn’t get better, it got worse. Then I thought, “Oh, you know, I herniated a disc,” but I didn’t have time to get it looked into because I still had solo private practice, OBGYN, and still had a kid to take care of and a husband. So eventually I had some scans done and ironically I had the scans done on my birthday. I wasn’t going to reschedule patients. And I was about, looked about two months ahead in my schedule and I went, “Oh, there’s like three people already scheduled for my birthday. I’ll take the day off.” Scans. I had the scans and I found out that I had breast cancer that had metastasized to every bone in my body. And my back pain was actually a fractured vertebrae and I was about to break my left leg from. Some I’m cured to the reality, which is somewhere around 25 to 30% of people with early stage breast cancer will have their cancer metastasize or spread to other parts of the body. Once that horse is out of that barn, you know, there’s no going back, there’s no cure for metastatic disease.
Adam: 04:27 Yeah, yeah. And you’re right. Yeah, there’s certainly no cure. And I know that the research is kind of what’s going to sort of help us tame cancer and nothing else will. And so we need to understand the biology of breast cancer, including the process of metastasis. I think I said that right. What are some of the promising new treatments for metastatic breast cancer that you’re excited about?
Kelly: 04:47 Yeah, there’s so many things coming down the pipe. I say I just, I need to live long enough for the next new thing to come out. So I have oestrogen receptor positive metastatic breast cancer and one of the things that’s super exciting is a drug that was just FDA approved. Alpelisib or Piqray is the name and it’s for people that have a certain mutation called PIK3CA. That was just approved like weeks ago and is super, super exciting. There’s also some work going on for people also that are oestrogen receptor positive, looking at certain mutations and finding drugs that can address that mutation. So there’s a trial called faktion F. A. K. T. I. O. N. looking at an AKT inhibitor and I swear , I mean who makes up these names for these drugs?
Adam: 05:38 I love that you said that, especially as a former physician, cause I often wonder that same thing.
Kelly: 05:45 I did a really good job when I was practicing speaking plain English. And my patients thought it was because to help them relate, but it was really because I can’t spell and pronounce all these things. This is an AKT inhibitor called [06:00 unclear] or something like that, that has shown in trials so far to double progression free survival in people who were previously on a drug. Like I’m on an aromatase inhibitor that have progressed on that aromatase inhibitor. So that’s super exciting coming down the pipe for those of us that are oestrogen receptor positive, there’s a lot of work going on in the HER2 positive space. There is a trial called Nala, which my daughter, my daughter’s 20 now, but the lion King is still her favorite movie. So I hear that trial and I just wanna start singing [06:34 unclear].
Kelly: 06:37 And this is a trial of neratinib plus capecitabine. Capecitabine’s already approved, neratinib’s approved in certain cases. And it’s again showing not only improved progression free survival, but improved overall survival, which means you live longer and showing that it may delay the time for someone to develop brain metastases. So that’s super exciting. But that’s, you know, that’s coming down the pike. And, and a big one with the whole, HER2 positive space are what are called antibody drug conjugates. There’s one approved now, but there are others that are in trial. A friend of mine is on a trial now for a drug that is DS801A and it’s an antibody drug conjugate of [00:07:21] hooked to a chemotherapy drug. So the chemotherapy drug is delivered only to the cells that have the HER2 two receptor.
Adam: 07:29 Oh wow.
Kelly: 07:29 It’s kind of like a smart bomb correcting the therapy where it needs to go. And she’s doing really, really well. A Lot of patients on this trial are doing well. And then for triple negative breast cancer, which is the third big category, there was a trial, I think the results were first published last year called Impassion 130 and it’s a drug called atezolizumab plus an already approved drug Nab-paclitaxel otherwise known as Abraxane. And they did an updated analysis recently. They presented it at, I think ASCO, the American Society of Clinical Oncology meeting this June. And it showed that a very small amount of improvement in progression free survival with this combination compared to placebo plus the Abraxane really expanded. So now that they’ve looked at these patients for an additional year or so, they’re really showing very, not only statistically significant, but personally and clinically significant improvement in progression free survival.
Adam: 08:38 Wow. Yeah, absolutely. And so, so I got to compliment you. You’re the first guest that has ever referred to a treatment as a smart bomb. So that was amazing by the way. But then, but I want to dig just a little bit deeper into sorta how some of this stuff works. So you know, metastatic breast cancers by and large are more resistant to standard therapies as you know. So like how are some of the treatments and therapies that you’re aware of or have experienced, like how do they limit the side effects to allow metastatic breast cancer patients to live longer with a better quality of life?
Kelly: 09:11 I’m super excited about this whole idea of the antibody drug conjugate because again, if we can identify some, and that’s one of the things, cause if we can identify something that the drug can grab onto on the cancer cell and you hook something else on like a chemotherapy drug so that again, it only goes to where it needs to go and its effect is there because with traditional IB chemo, traditional cytotoxic, IB chemo, the things that that a lot of us were on, if you’re early stage, the taxol, the cytoxan, those kinds of drugs. Yeah, they’re trashing every cell in your body and it’s really hard on you so we can get that chilling effect just where it needs to be. That is there’s so much potential for being very effective against the cancer. Like I always like to say, may your drug be tough on your cancer and easy on you.
Adam: 10:06 Yes, I love that.
Kelly: 10:07 And the other interesting area of research is harnessing our own immune system to fight the cancer. They’re studying things called bi-directional antibodies. And again, if you think about it as there’s a hook on one end that catches onto the cancer cell, there’s a hook on the other end that catches onto the immune system and activates the immune system. So the immune system then recognizes that cancer cell is what it needs to fight, but not the normal cells in your body. That’s another really interesting area of research that I’m super excited about because I think the more we can use what our body has, the better off we’re going to be. The longer, the more durable response we’re going to have and the less toxicity we may have on the rest of our body because it’s not just living a longer life. It’s living a better quality life as well.
Adam: 11:08 That’s right. Yeah. And by the way, thank you for describing it the way that you do it makes it like, I understood what you said, so that’s winning right there.
Kelly: 11:18 This stuff is complicated,
Adam: 11:19 It’s really good. So when you say like it hooks onto this. Oh, that makes perfect sense. I love that. Like let’s do more of that. You know.
Kelly: 11:26 That’s why there will never be ‘the cure’ because breast cancer is not a single disease. There’s subtypes and theres subtypes of subtypes, so it’s so complex. What I’m super excited about, is Komens 2020 career catalysts grant, these competitive grants are focused on liquid biopsies in the metastatic setting, so liquid biopsies or blood tests that look for either cancer cells that are circulating in the bloodstream or DNA from the tumor that’s circulating in the bloodstream. This is, I think this is an area of research that I am so excited about on a couple of different levels. One is if we can look for circulating cancer cells, even in an early stage setting and at a certain time point, if someone has circulating cancer cells, we then know that they’re at an increased risk for developing metastatic disease or developing a local recurrence. They can be monitored more closely and may have treatments started. There have been a couple of studies now that have shown in the metastatic setting that looking at circulating tumor cells and circulating tumor DNA can pick up progression about three months earlier than the best imaging tests can pick it up.
Adam: 12:49 That’s amazing.
Kelly: 12:51 The question right now that’s being looked at is does changing therapy three months sooner make a difference? And to me it makes sense that if you have less disease to treat that you’re going to be able to treat it more successfully.
Adam: 13:04 Yeah, I don’t see how earlier can’t be better.
Kelly: 13:07 So that’s really exciting. And also one of the things that I feel passionately about, you can talk to people who’ve ever been at any of the big cancer conferences because I invariably get up, go to the microphone and say, “I firmly believe that every single solitary advanced and metastatic cancer patient, I don’t care what kind of cancer it is, should have these liquid biopsies performed right now,” we may not be ready to say, Oh, we identified these mutations and we have treatments for all these mutations. We’re not there yet. But if everybody’s tested and we figured out that, you know, 20% of people have mutation X, Y, Z, well then researchers know they need to study mutation X, Y, Z. Exactly right. It can inform the direction of research. So that work, that Komen’s going to be funding, I mean, that is their focus of their career catalyst grant for 2020, is liquid biopsies in the metastatic setting. And I’m a Komen advocate in science, so I’m really excited about maybe being able to review some of these grants and give the patient perceptive because Komen does look to advocates to give an opinion on potential grants because the advocate, the patient voices is so- what’s important to us is important to Komen.
Adam: 14:29 Yeah, that’s great. That’s great. So how can someone diagnosed with metastatic breast cancer find out more about new and emerging areas of treatment and clinical trials?
Kelly: 14:42 Well, there’s a couple of different ways. Komen, member of an organization called the Metastatic Breast Cancer Alliance and I’m also an independent advocate member of the same group. So there is an app that this organization has, Komen’s partnered in all of this, that was about to start matching patients to trials. Komen Itself has a clinical trial -not a search engine, but a real live person will talk to you. Go into komen.org and searching for clinical trials, you can actually talk to a trained nurse or trained navigator that will help you find a clinical trial. There’s clinicaltrials.gov which is the, the site where all clinical trials are registered. It’s sometimes challenging. Even somebody with my background can have a little trouble waiting through a clinical trials.gov so I think Komen has some really wonderful resources and partners with other organizations that have really great resources to help us find clinical trials.
Adam: 15:51 I love that. All right, so last question. If you have just one piece of advice that you can give to someone diagnosed with a breast cancer recurrence or metastatic breast cancer, what would that advice be?
Kelly: 16:05 It’s actually a two part piece of advice and the first piece of advice is just breathe, just just breathe. And the second piece of advice is get a second opinion from someone from a center that specializes in metastatic breast cancer. Most of us like me are treated in the community and while my community oncologist and by community, I mean I only have to drive 45 minutes each way on a good day, but he’s seeing patients with all sorts of cancers. I have sought a second opinion from a National Cancer Institute designated comprehensive cancer center with an oncologist who is one of the world’s leading experts on metastatic breast cancer. We can also utilize technology because some of these comprehensive cancer centers will do second opinions via telemedicine via Skype. I think it’s super important that all of us with metastatic disease have someone that that’s all they do in our back pocket for when, for when we progress, for when we need to look for a clinical trial.
Adam: 17:13 Yeah, that’s great. Wow. That is so, so, such good advice. Well, Kelly, this has been amazing, inspiring. I think you could be a professor if you wanted to be. You have a way of teaching that. I really appreciate. So thank you so much for joining me on the show. I really enjoyed our talk.
Kelly: 17:30 Thanks a lot, Adam. I might have to think about that. I can’t practice medicine anymore because of my disease, but you know, Hey, maybe I could teach.
Adam: 17:37 You’re great at it. I gotta tell you, you’re great. So thanks so much, Kelly.
Kelly: 17:41 Thanks Adam.
Susan G. Komen launches the MBC Fund!
Susan G. Komen is proud to launch the “MBC Fund” specifically designed to spur scientific discoveries and support those women and men living with Metastatic Breast Cancer, building on Komen’s $210 million investment in metastatic breast cancer research. For more information on the MBC Fund and how to support it, visit www.komen.org/MBC.
Into Thy Heart by Ivan Chew. Ad music is Blue Skies by Silent Partner. The Real Pink podcast is hosted by Adam Walker, produced by Shannon Evanchec and owned by Susan G. Komen.