[00:00:00] Adam Walker: From Susan G Komen, this is Real Pink, a podcast exploring real stories, struggles, and triumphs related to breast cancer. We’re taking the conversation from the doctor’s office to your living room.
Chemotherapy or chemo is often associated with cancer treatment and hair loss. But what do you know about it? The term preventative chemotherapy has been mentioned in the media recently in relation to Princess Kate’s cancer journey. Leaving many people wondering exactly what that means. We’re here today, joined by Komen Scientific Advisory Board Member, Dr. Lisa Carey, who will help us understand the evolving role of chemotherapy, preventative chemotherapy, and more in the treatment of breast cancer. Dr. Carey, welcome to the show.
[00:00:41] Dr Lisa Carey: Thank you so much. It’s a pleasure to be here.
[00:00:43] Adam Walker: I’m very happy to have you, like I mentioned in our pre show conversation, I’ve talked to so many people that go through chemotherapy and I couldn’t tell you anything about it, not more than maybe a sentence. And so hopefully I’ll get some education along with our listeners today. So let’s start there. What is chemotherapy? What is it? And what’s its purpose?
[00:01:05] Dr Lisa Carey: Chemotherapy refers to a group of chemicals that kill cancer cells.
They’re not targeted in the sense that many of our more modern treatments are, more focused on a particular element of the cancer cells. These are more global, which, if you think about it, that’s why it’s got the bad wrap, because in addition to killing cancer cells, because they aren’t very specific, they have other side effects because they affect normal cells too.
And that’s why people lose their hair their blood counts can go low. They might have nausea, things like that. And that’s because chemotherapy in aggregate are, they’re not dumb drugs, but they’re not as smart as we’d like to be.
[00:01:47] Adam Walker: Got you. Okay. That’s, I guess that explains also why it’s the main breast cancer treatment, right?
So chemotherapy is the main breast cancer treatment. It’s the thing that comes to mind when we think about cancer treatment. How is the use of chemotherapy? Like, how has it been used to treat breast cancer over time? And how’s it changed over time?
[00:02:06] Dr Lisa Carey: You know what you just said is exactly right.
So chemotherapy has been used in every kind of breast cancer because it isn’t focused. So it has an effect in a good way. Generally, we use these drugs because the good part outweighs the bad part.
And, in truth, some of the nearly 40 percent decrease in mortality and death from breast cancer is because of the effectiveness of chemotherapy. Now, the truth is that we now have really smart drugs that have had bigger impacts within certain focused areas, types of breast cancer, but chemotherapy is the only thing that works in everybody.
[00:02:46] Adam Walker: Okay. And are the more focused treatments, are those a different type of chemotherapy or are those totally different?
[00:02:52] Dr Lisa Carey: Not chemotherapy. So these, I’m talking about targeted therapies. Let’s just, some breast cancer has been doing targeted therapy and precision medicine, right?
That’s the term that’s used frequently for years and years. We were one of the “OGs” of precision medicine because more than half of breast cancers have the estrogen receptor in them, and when you have the estrogen receptor, you can target that. You can either target it by starving it of estrogen or by targeting that receptor.
So some of the very first targeted therapies in any cancer were actually the estrogen receptor targeted therapies that have been around for decades. So we’ve had those for many years and we have a whole lot of them now. There’s also HER2. So the other main group, so breast cancers divide up into those that are hormone receptor ER positive and those you can use anti estrogens.
HER2 positive, which is about 20 percent of them where that’s the defining characteristics. They have too much of this protein called herH E R2 and you can use anti HER2 drugs in them again, another targeted therapy. The last group is the triple negatives. So triple negative is negative because it doesn’t have any of the hormone receptors or HER2. In a sense, we use chemotherapy in all of them. But we’re dependent on it in triple negative because it doesn’t have any of those targeted.
[00:04:16] Adam Walker: Because that’s the thing for triple negative versus the thing plus something else for the others is what you’re saying. Okay. That’s profoundly helpful.
Thank you. All right. So let’s talk about the preventative chemotherapy. It’s been in the media a lot, apparently related to princess Kate and her cancer diagnosis. It seems like this is a new term for people. Certainly a new term for me. So can you explain what preventive chemotherapy is and how it’s used for breast cancer?
[00:04:44] Dr Lisa Carey: Sort of. The problem I have is I don’t know exactly what the palace meant in the situation of Wales. My guess is what they were referring to is Chemotherapy and what we call curative intent treatment. So that’s where, if you do a certain, usually it’s surgery, some sort of medical treatment, sometimes radiation; if you do those things, you are trying to complete a course of therapy, and then you stop, and at that point, hopefully the patient will go the rest of her long and healthy life and never have cancer recurrence.
So in a sense, it’s called preventive. That’s not the term that we usually use for it, but it is true that we call that kind of therapy curative intent therapy.
It oftentimes does include chemotherapy along with many of the other things we just talked about. And as the counter distinction to that is metastatic cancer into the spread throughout the body where we don’t realistically have a chance of curing it. So instead we’re trying to manage the cancer, rather than cure it.
And so I think what they were referring to in those press releases was the use of chemotherapy to help augment the cure rate of whatever cancer she has, which I don’t think anybody quite knows yet.
[00:06:05] Adam Walker: Got you. Okay. So, let’s talk- and you mentioned this, or you alluded to this earlier, that chemotherapy is a difficult treatment for patients to tolerate. So can you talk a little bit about what that looks like and why it is difficult for them to tolerate it?
[00:06:22] Dr Lisa Carey: Sure, it’s difficult to tolerate because of what I said before, which is that it has more effects on the surrounding cells, the other normal parts of your body than a more targeted drug, right?
A targeted drug has most of its effect on the thing that has the target, which if you’re choosing your target wisely, you choose one that is seen a lot on the cancer and not very much on everything else in your body, right? So chemo doesn’t have as much of that opportunity. So it tends to have more side effects.
Now, there are a lot of different chemotherapies. They get all lumped together, but in truth there are many different kinds of chemotherapy that work through
different mechanisms. They kill cells through different ways. And so that’s why some chemotherapies, for example, make your hair fall out and others do not.
Some, are classically associated with nausea and others don’t have any nausea. Some give you neuropathy, right? That’s that numbness and tingling of the hands and the feet and others have zero chance of neuropathy associated with them. And that just has to do with the nature of how the chemotherapy is working, because I’m calling it not precision medicine, but it’s not exactly done, right?
Chemotherapies are designed to kill the cells using a certain mechanism and depending on that mechanism, different types of side effects.
[00:07:45] Adam Walker: Okay. And so you mentioned, and maybe this should have occurred to me, so you mentioned there’s different types of chemotherapies. I’ve heard many patients, or many, I should say, interviewees on this show mentioned the red devil. Is that sort of one of the more common ones?
[00:08:01] Dr Lisa Carey: It is. So the red devil is a drug called doxorubicin or adriamycin. Those are the two names that goes by ones. It’s proper name and the other is the trade name. It is amongst our most effective drugs, but it also has certain side effects that are obnoxious while you’re receiving the drug. It can be nauseating and makes your counts go low, it does make your hair fall out. Things like that.
[00:08:29] Adam Walker: Yeah.
[00:08:29] Dr Lisa Carey: All of which to be frank, I’ve been at this for a while and we can manage all of those things now much better than a few years ago because we have a lot of drugs to help with those.
[00:08:40] Adam Walker: Yeah.
[00:08:40] Dr Lisa Carey: This, the more troublesome element of this particular drug is that it can cause heart damage. It’s rare, but it’s real and it can cause leukemia. So those are things that happen long after you’ve given the drug and while they’re rare, they’re clearly attributed to the drug. Those are the main reasons that we try to avoid it and a good deal of the evolution of Chemotherapy use is away from using that particular class of drugs for exactly that reason.
[00:09:11] Adam Walker: All right. Thank you. I appreciate that.
[00:09:12] Dr Lisa Carey: It’s famous for its color. It’s also the only one they can tell what color it is.
[00:09:16] Adam Walker: That’s true, all right. And so, outside of preventative chemotherapy, are there other kinds of adjuvant therapies that aim to prevent breast cancer recurrence?
And could you tell us a little bit about those?
[00:09:27] Dr Lisa Carey: I think when we talk about preventative chemotherapy, if we’re interpreting that phrase correctly, meaning chemotherapy given as part of an effort to cure a patient, you can either give that before surgery that’s called neoadjuvant, right?
And that’s actually a common way to give it now. Or you can give it after surgery as called adjuvant. Either way it’s done as part of an effort to cure the patients. It depends on the kind of cancer, which chemotherapy drugs we use. But when we’re using chemo for the most part, we use multiple different drugs that work in slightly different ways.
So it would be unusual in the preventive sense, to use only one drug. It’s typically multiple different drugs. Now, when we’re treating metastatic disease, where we’re trying to control the cancer and to be very mindful of quality of life, because essentially they’re being treated for lifelong, then we typically use one drug at a time.
[00:10:25] Adam Walker: Gotcha. And why is it just one drug at a time for that?
[00:10:28] Dr Lisa Carey: Because there isn’t, you aren’t trying to get everything done, augmenting the response. You’re trying to control the cancer and not put the patient in bed sick, right? Because you’re going to be treating her for hopefully many years trying to manage this.
And that’s where a lot of times we try to get away from chemotherapy, until the other things don’t work.
[00:10:48] Adam Walker: Got it. Okay. Now, as you think about the future, what types of tools, what types of treatments, what types of drugs do you think will come available to help fight cancer, to help reduce the risk of recurrence?
[00:11:01] Dr Lisa Carey: You know that falls in two categories. The first is that the non chemotherapy the more targeted drugs, the precision medicine
drugs, those are getting better and better all the time and there’s no reason to think that isn’t going to keep going. And as they get better the need for chemotherapy that’s not targeted goes down, right?
[00:11:20] Adam Walker: Oh, yeah. Okay.
[00:11:23] Dr Lisa Carey: So there’s a whole bunch of patients who 20 years ago would all be getting chemotherapy. And now we have the tools, we have genetic tools to say whether somebody would benefit from it or not, etc. And we’re using much less chemotherapy. Because the other drugs got better and our ability to test the tumor to see if it needs chemo or not got better.
So that’s the benefit. Part one is, we’re going to get smarter about who actually needs chemo and so chemo use will go down. The second part is the chemo itself is evolving. So in metastatic cancer and in some non metastatic cancers, we use these drugs called antibody drug conjugates, ADCs. What those are is a, typically it’s an antibody, so it goes after a target on the cancer cell and it carries on it a chemo.
So it’s like a Trojan horse, it’s still chemo, but it’s chemo given in a semi targeted way. So the chemo itself is getting more targeted and more effective for that reason. And there’s no question that’s going to become, it may become the only way we give chemotherapy in the future.
Maybe not entirely, but that’s the direction we’re going in is the chemo itself is moving away from the same old, and into much more sophisticated ways to package chemotherapy to be more effective and safer.
[00:12:42] Adam Walker: So like looking back over, let’s say, the last 30, 40 years, it sounds to me like chemo was, if you’ve got a hammer, everything looks like a nail. So it was like, it was a hammer for everything. And it’s, and basically it’s less and less of that. And I think what I’m hearing you say is, the use and the need for chemo is going down because these other more targeted therapies are on the rise and taking its place.
Is that right?
[00:13:06] Dr Lisa Carey: Yeah, yes. And we’re also getting smarter at biologically defining the cancers to figure out if some of them are the kind that really are, don’t need chemo.
[00:13:18] Adam Walker: Oh yeah. Because 30 years ago we would have just given everybody chemo and maybe they had a cancer that didn’t even respond to chemo.
[00:13:23] Dr Lisa Carey: We didn’t even know about HER2 positive disease until, 1998.
[00:13:28] Adam Walker: Wow. That’s amazing. So as we learn more, the medicine improves to better support patients. I love that. Yes. Okay. I was going to ask you like, what’s the future of chemo as it relates to breast cancer?
But I think I’ve heard you say general chemo is going to decline and more targeted chemo delivery is going to increase as well as more targeted treatments. Is that right?
[00:13:45] Dr Lisa Carey: Yes. So I think chemo in general. No matter how you package it is going to go down.
[00:13:50] Adam Walker: Okay,
[00:13:51] Dr Lisa Carey: And if you’re going to give chemo, we’ll be giving it smarter ways more packaged ways more sophisticated ways.
[00:13:57] Adam Walker: Wow. Okay, that’s fantastic. That’s good news. Okay, I agree. I like that. I guess last question, where can our listeners find more information about chemo?
[00:14:08] Dr Lisa Carey: Oh, there’s some really nice websites. The American Cancer Society has a nice website that has chemotherapy, some descriptions, what to expect, et cetera.
The National Cancer Institute has a great website that has all sorts of resources for cancers, the nature of cancers, the treatments, et cetera. So I would start with those and I would also be very leery of many of the other websites that have a lot of misinformation.
[00:14:33] Adam Walker: Yeah, Google is, often a very dangerous place for medical.
Dr. Carey, it’s been so good to have you on the show. I genuinely feel like I have a much better understanding of chemotherapy at this point. Are there any final thoughts you’d like to share before we wrap up?
[00:14:48] Dr Lisa Carey: No, I think that the truth is that, we still give chemotherapy.
We give it thoughtfully and when patients need it. And I think patients should realize that there’s a lot that goes into that decision making process and to be frank, most of my patients do just fine, I give a lot of chemo and even if they have to have chemo, they do really well, most of them just live their lives fairly normally throughout that, so they shouldn’t be too scared.
[00:15:14] Adam Walker: I love that.
All right. Dr. Carey, thank you so much for joining us on the show today.
[00:15:19] Dr Lisa Carey: It was my pleasure. Thank you so much
[00:15:21] Adam Walker: Thanks for listening to real pink a weekly podcast by Susan G. Komen for more episodes visit realpink.komen.org and for more on breast cancer visit komen.org. Make sure to check out @susangkomen on social media. I’m your host Adam. You can find me on Twitter @AJWalker or on my blog adamjwalker.com.