Dr Holly Keane is a Breast Surgeon at the Peter MacCallum Cancer Centre in Melbourne, with an interest in the areas of pain management and tailored screening for breast cancer patients.

We spoke with Dr Keane about pain after breast cancer therapy, its implications in day-to-day life for breast cancer patients, and some ways to reduce pain during recovery.

“Pain, including post mastectomy pain syndrome, is something that I’ve looked into quite substantially. I’m also very interested in the screening of high-risk women and tailored screening. All of these projects I started working on within my fellowship in San Francisco and I’m trying to continue back in Melbourne, Australia.”

How common is pain after breast cancer therapy? Is it something that affects everyone?

“So, I wouldn’t say all women, but it is a majority. In the literature, the incidence of post mastectomy pain syndrome is between 25% to 60%, but I think it could be even higher than that simply because clinicians don’t always ask about it and it’s not always identified or documented.”

What are some ways that people can reduce pain after breast cancer therapy?

“So, the lifestyle interventions that we talk about include exercise and having a normal weight, but that isn’t specific to post mastectomy pain. It’s not really been shown to decrease that incidence, but it improves breast cancer specific survival, and we know that it improves outcomes during chemotherapy and other breast cancer treatments.”

“But the ways to specifically reduce pain can include oral painkillers, some neuropathic pain tablets work as well. But my interest and what I was talking about at the Breast Cancer Trials conference this year was an injection specifically into the nerve that is cut during mastectomy, that comes out of the chest wall and it forms a little neuroma, which can be targeted with local anesthetic and with the steroid injection to decrease this neuropathic pain.”

“So, simply we must get clinicians, surgeons, oncologists, radiation oncologists just to ask about the presence of these symptoms. Asking the patient what type of pain they’re experiencing, is the pain felt under light touch or are they experiencing constant pain over the mastectomy field or over the breast or reconstructed breast.”

“Once you know the answer, if the patient said yes, that they do get that sort of pain, you just simply examine the patient in the clinic room. So, they just lie down, you palpate along the inframammary fold. And if there’s what’s called a ‘trigger point’, which is when you palpate with your index finger and your thumb and the patient sort of hits the roof with pain, you know that there’s a neuroma lying underneath. From there you can simply grab a syringe with the local anesthetic and the steroid in the mix in the syringe and inject it directly into the patient. And many women will have instant results, which is very important and extremely impactful for them.”

“So, we should ask about it with everyone who’s had breast cancer surgery. Hopefully we can get the word out that this is available and is opportunity for all patients. People who treat breast cancer need to be aware of this intervention, and everyone should be able to do it including surgeons and you know other physicians as well.”

As an addition to this, how important is diet and exercise in reducing pain after breast cancer therapy?

“So, there isn’t great evidence specifically for post-mastectomy pain, but certainly to help women get through chemotherapy, endocrine therapy, and radiotherapy, exercise and diet is helpful and certainly exercise increases resistance to specific pain.”

“So, I would encourage all my patients to regularly exercise and it’s going to be moderate to high intensity exercise, three to four times a week. So, getting your heart rate up and sweating. In terms of diet, I mean we heard about diet yesterday during one of the talks. There are some links, but certainly a well-balanced diet is strongly encouraged.”

What advice would you give to a patient who was experiencing this sort of pain after their breast cancer therapy?

“Most importantly, let your specialist know, and then hopefully they will be aware of this simple intervention, and if they aren’t able to provide the intervention themselves, they can refer you to a surgical oncologist to be able to perform the injection.”

What are your hopes for the future of breast cancer research?

“That’s a good broad question. Really, my hope is in the prevention setting. You know, we do focus on this area quite a lot and have to because breast cancer is so common. There is a large focus on the treatment of early breast cancer, then the adjuvant treatments, and then unfortunately, if it gets to the metastatic stage, we need to consider all the different drug combinations and changes.”

“But we really need to be preventing this before it happens, so we don’t have to do all these highly scientific drug trials. If we can prevent more cancers from occurring, this will have a great outcome and that is why I think we should really focus a lot of our research on prevention, because we won’t need all these extra treatments if we can prevent it in the beginning.”

“We know that chemotherapy is very effective and it certainly reduces the risk of cancer returning. In women that have hormone-receptor positive early-stage breast cancer, we also give endocrine therapy. And that is very effective also in reducing the risk of the cancer returning.”

“So, if someone has a very high-risk breast cancer, they will typically get both chemotherapy and endocrine therapy. Whereas other women whose cancer is not as risky will be able to have the endocrine therapy alone without the chemotherapy.”

“One of the challenges we face in treating hormone-receptor positive breast cancer is knowing who really needs the chemotherapy. So, we need to work out who are the people that have got a high-risk of the cancer returning, and the chemotherapy is going to help reduce that risk, and who are the people that we can just give the endocrine therapy to and not have to give them chemotherapy because chemotherapy has a lot of side effects.”

“Those side effects can be quite short-term, so things like hair loss, nausea, tiredness, infections, but there are also some serious long-term side effects. So, it can cause peripheral neuropathy, there is also a small risk of heart damage and secondary cancers. So, we need better ways of really working out who are the people that really need the chemotherapy and who doesn’t.”

“And so that’s where these multigene assays have come into the picture, because they’re sort of RNA tests. They look at tumor samples predominantly in ER-positive, HER2-negative tumors. And they look at a whole lot of different genes that predict for the risk of recurrence.”

“So, there’s several of these assays and they’ve all been shown to be effective in classifying tumors into low and high-risk. And that means if you’ve got a low-risk cancer, it’s less likely to return and less likely to need chemotherapy. Whereas a high-risk cancer is the one that we really want to make sure we’re doing what we can to reduce the risk of it returning, which would mean giving it chemotherapy.”

Do these Assays differ from young women to post-menopausal women?

“So, most of the research that’s been done on these assays has been in predominantly post-menopausal women. So, a lot of the early retrospective validation studies were mainly in studies where the women were post-menopausal.”

“There have been three large prospective studies that have been completed with different assays. And in each of those studies, about one third of the women were pre-menopausal. So again, most of the women were post-menopausal.”

“There’s less data on the pre-menopausal women, but certainly when we look at the results of these prospective studies, what they showed was that you could select a group of patients who had hormone-receptor positive, HER2-negative breast cancer, and these studies were done in women who were lymph node negative or had up to three involved lymph nodes.”

“And the assays were able to look at a group who had a low genomic risk of recurrence. And overall, in each of these studies, they showed that in that group with low genomic risk, the group that, if they received endocrine therapy alone, they did just as well as if they received chemotherapy and endocrine therapy.”

“So, there was no benefit from adding chemotherapy. However, when you look at just the one-third of patients who were pre-menopausal in these studies, again, when you pulled out the patients with low or intermediate recurrence scores, the women that got chemotherapy did better.”

“So, there was a clear benefit in the chemotherapy in reducing the risk of these cancers returning. For some reason we’re seeing the post-menopausal women not getting a benefit from chemotherapy and the pre-menopausal women with the same recurrence scores getting a small benefit from chemotherapy.”

“When we look at the reason why we might be seeing this difference between the pre-menopausal and post-menopausal women and the benefit of chemotherapy, it’s very likely that the chemotherapy is causing an early menopause in the pre-menopausal women and that’s what the benefits coming from.”

“So, we’ve known for some time that giving ovarian function suppression to young women with hormone-receptor positive breast cancer, reduces their risk of the cancer returning. And so, we know in women who are close to the age of menopause when they get chemotherapy, they’re likely to go into an early menopause.”

“And in the studies in young women, where we looked at the gene expression assays, the women who were benefiting the most from chemotherapy were those over the age of 40, who were more likely to go into menopause. So, I think the next big question really is yes, there’s a benefit from chemotherapy in these women, but is it from ovarian suppression or is the chemotherapy having an effect independent of ovarian suppression?”

“Unfortunately, in the studies that have been conducted so far, we can’t answer that question because in all these trials, the endocrine therapy that was given in those young women was suboptimal. Most of it was tamoxifen only, and it was less than 20 percent of women across those studies that received ovarian function suppression.”

“So, if you’re giving maximal endocrine therapy in a young woman, which is the ovarian function suppression and aromatase inhibitor, we don’t really know if there is any benefit to chemotherapy. And that’s why we need more research to answer this question.”

What are your hopes for the future of breast cancer research?

“My hopes for the future of breast cancer research are further along this same line. I hope that we get better at firstly giving targeted therapies, and therefore have less reliance on chemotherapy, and that we become better at working out who really needs the chemotherapy. So that the people we’re giving it to we know are really benefiting from the treatment, and we’re not giving it to a whole lot of people that are not going to benefit chemotherapy and all the unwanted side effects.”

“So, I think that for the future I’m hoping we see a lot less chemotherapy use, and a lot more targeted therapies and therapies with less side effects.”

For many young women with a breast cancer diagnosis, starting a family following their treatment can be a primary point of concern. The POSITIVE clinical trial investigated if it was safe to temporarily stop endocrine therapy in young women with oestrogen-receptor positive breast cancer, who wanted to become pregnant after their breast cancer diagnosis.

Christobel Saunders is a Board Director at Breast Cancer Trials and a Professor of Surgery at the University of Melbourne, Royal Melbourne Hospital, and the Peter MacCallum Cancer Centre, and we spoke to her about the outcomes of this clinical trial.

“So, the POSITIVE trial was a large international trial aiming to recruit around 500 women from around the world. And the question we wanted to answer was one that many young women themselves will have. That is, I’ve had breast cancer and I really want to have a child after my breast cancer. Is it safe to do so, and if so, how should I go about that?”

“We know that women who’ve had breast cancer and had the treatments for breast cancer have a lot lower fertility. In other words, having had chemotherapy, being somewhat older, and then having to have anywhere between five and ten years of endocrine therapy means that by the end of all of that, your chance of actually having a child is very low.”

“And yet we know that young women who’ve had breast cancer, many will want to go on to have a child, either a first child or another child if they have one. And that’s a really important issue for women, particularly as we know that breast cancer is fairly common in young women. Around 4,000 women under 45 are diagnosed in Australia each year with breast cancer.”

“Most of those will do very well and survive, and therefore there are literally tens of thousands of women who’ve had breast cancer. And for them, future fertility, and having a family is really important.”

“But what had never been answered in a prospective manner was how safe that could be. So, the study was really aimed to look at the safety of that. And our primary outcome of the study was breast cancer free interval. In other words, how often was it that breast cancer was likely to come back.”

How can a breast cancer diagnosis affect a women’s fertility?

“So we know firstly that breast cancer is probably slightly more common in women who haven’t had children. So, a lot of younger women diagnosed with breast cancer won’t have completed their families. We know that having chemotherapy, which many young women of course will have, essentially ages your ovaries by around 10 years.”

“If you’re 35 at diagnosis, it can age your ovaries to be 45, so clearly less likely to have a child. And importantly, having endocrine therapy for a large proportion of women who have endocrine sensitive tumours will also mean that you can’t get pregnant whilst you’re on that endocrine therapy.”

“So this study was aimed at those women with the ER-positive cancers and the real question was, can we stop that endocrine therapy for a while, or interrupt it, asking them to then restart it. And during that period of interruption women could attempt to get pregnant either naturally or if they’d had IVF, for example embryo storage, they could do it that way.”

“This study looked at the safety of interrupting it for a while in an attempt to get pregnant and then go back on up to 10-years of endocrine therapy to make sure your cancer doesn’t come back.”

What were the results from this study?

516 women were enrolled in the positive study, which was conducted across 20 countries, and 497 of those were followed for pregnancy status. Among the 497, 368 women had at least one pregnancy and 317 had at least one live birth.

By three years following initital treatment, the cancer had returned in approximately 9% of participants. These results were similar to those seen in a group of premenopausal women participating in a similar study without a treatment pause.

Study Chair of the POSITIVE clinical trial, Professor Ann Partridge highlighted that “the POSITIVE trial provides important data to support young patients with hormone receptor-positive early breast cancer who are interested in a pregnancy, taking a break from endocrine therapy to pursue one.”

What are your hopes for the future of breast cancer research?

“Well, in an ideal world, I would become redundant in the next few years, and we would no longer need breast surgeons and no longer need breast cancer researchers, but clearly that’s not going to happen. So, I think that’s a multi-pronged question”, said Professor Saunders.

“We obviously, ideally, would like to try to prevent so many people being affected by breast cancer. It’s not just whether you survive or not, but it’s having the diagnosis, having to go through the treatments, and having the long-term survivorship issues. So trying to avoid breast cancer would be the ideal way, and we are of course looking at ways to do that.”

“We also want to try to and make more women survive, but also have a better quality of life. And I think that’s really important, addressing those quality-of-life issues. And that’s something that the POSITIVE trial is trying to do, it fits into that bracket if you like, of really impacting on survivorship because for a young woman having a normal life after breast cancer is really important and having a family is an important part of that normal life.”

Dr Ben Green is a breast surgeon based in Brisbane, Australia, with an interest in the current oncoplastic and reconstruction capabilities in 2023.

While more women today are surviving breast cancer, they can still be left with post treatment deformities to their breasts from surgery.

We spoke with Dr Green about breast reconstruction, techniques to preserve the breast and the importance of using the breast shape to your advantage during reconstruction to achieve the best outcome for patients.

“I’m talking tomorrow on the process of training breast surgeons in 2023 and beyond. And the whole breast training program has really changed over the last 10 years or so. Originally everyone sort of just found their own jobs and it was all a bit haphazard, and now it’s a very structured program over two years, where people coming out of surgical training can then move into it if they want to sub specialise.”

“The idea is that at the end of that two years they’ve sort of had a broad exposure of all the sort of modern breast surgery, and oncoplastic training techniques, and that they can then move into their own practices going forward.”

What is oncoplastic breast surgery?

“Oncoplastic has sort of really come into view in probably the last 10 years really and has gained that sort of momentum now and is becoming standard practice, or at least it is becoming standard practice in breast surgery. And the good thing is that a lot of women survive breast cancer, however they’re often left with the deformities that we create as the surgeon, by taking out the lump.”

“So, we want to try and use techniques where we have the aesthetics of the breast in mind, and you can sort of use the breast shape to our advantage to create a new breast shape, or at least maintain the shape of the breast, or sometimes even improve the shape of the breast.”

What are the standard oncoplastic and reconstruction capabilities in 2023?

“So, at the moment most of the people coming into breast surgery have finished their general surgical training and then they move into subspecialty training. So, they apply to the post fellowship training program. And we’ve just had our applications for that this week while we’re here at the conference.”

“That’s a two-year program, so they go through a structured two-year process, which is a combination of in-job training, there’s courses they have to do specifically in the oncoplastic space, so a level one and a level two course where there’s different types of procedures that we do, and more complexity as you go from level one to level two. And at the end of that, hopefully they can gain the exposure so they can start using those techniques in their own practices.”

“For other surgeons who might be a few years out and want to do oncoplastic surgery because they see the value in it, which is hopefully most surgeons now, there are other ways. There’s the Sydney University Master’s or a graduate certificate in oncoplastic surgery, which gives you all of the core curriculum that you need to learn about the oncology and the plastic surgical techniques to do the surgery.”

“So, there’s sort of a theoretical component to it. And then combined with the courses that breast surgeons run, you can get the practical exposure. I think everyone who works on those programs are quite open to mentorship and training. And I went and visited various surgeons who utilise different techniques, to learn how they do things, and that’s sort of how you learn.”

“So, the process is really within the PFT program. It’s a two-year process where you just focus on breast surgery. And yes, those fellows will be providing some general surgical components to their hospitals that they work in, but primarily they have to do breast surgery. So, in the first year the focus is more on the oncology component, including standard safe mastectomies, breast conservation surgery and sentinel node surgery.”

“And then in the second year the focus is very much on the oncoplastic techniques, and they’ll start with the sort of the simpler techniques with what we call mobilisation of breast tissue, to fill the defect, through to more complex things where we might completely change the shape of the breast. And they take more training and more time.”

“So, we set certain criteria of how many procedures people need to do before we would deem them as being competent, and they’re assessed in their competencies, so they do a number of in-training assessments to break that procedure down into various components until they’re deemed as being capable of doing it on their own, unsupervised. So, by the end of the two years, they’ve hopefully got the core procedures down pat.”

What are your hopes for the future of breast cancer research?

“Well, this is only in the oncoplastic setting, but I would personally like to see that this become standard practice. At the moment there’s still some areas where it’s not considered to be the standard practice, it’s a little extra, but I think that’s becoming old school.”

“So, I’d like to see that all breast surgeons are doing oncoplastic surgery, and that it becomes normal. There are huge amounts of research that have been done and will continue to be done that show the benefits to women, that they’ve got improved patient reported outcomes, that they have higher self-esteem, they look at themselves in the mirror when the surgery is finished and they’re not covering themselves up. They’re not feeling like they’ve lost their femininity, and they have either an improved shape, or have maintained the shape of their breast.”

“This gives them confidence going forward and there’s been a lot of research in that space, and I think that’ll continue over the years.”

Dr Cindy Tan is a dietitian working in a cancer survivorship clinic at the University of Sydney, who is researching lifestyle interventions to improve diet and exercise for cancer survivors, as well as the psychosocial aspects of cancer recovery.

We spoke with Dr Tan about the importance of dietary considerations for patients with early-stage breast cancer.

“The topic of dietary consideration is important because obviously diet is a very significant topic for our breast cancer survivors, and ultimately everyone wants to improve their diet. This is one of the reasons why I would like to focus on this topic, and I’m hoping that we can eventually come up with a lifestyle intervention that can improve the diet and exercise levels in breast cancer patients to improve their quality of life and clinical outcomes.”

Why is it important for someone to consider their diet when diagnosed with breast cancer?

“Well, we know that a good diet can improve one’s health in general, and everyone, even though they may not say it, but everyone knows that a good diet is important. We have lots of people trying to improve their diet since receiving a diagnosis.”

“At the survivorship clinic, we ask the patients who come through after they have completed their treatment, have you made any dietary changes since receiving the cancer diagnosis? And we found that 58 percent of them say that they have made some form of dietary change. And at least on average, this will equate to two dietary changes per patient, but it can range from one to seven.”

“So, everyone wants to do something about it, and I guess diet is something that people feel that they can control, because it’s within their capability. From a research point of view, we know that good nutrition can improve mental wellbeing, as well as provide nutrients that can support a person to go through their cancer treatment.”

Do dietary considerations for patients with early-stage breast cancer differ to those with advanced breast cancer?

“So, the short answer is no. I guess when people talk about diet, we would usually ask what they are thinking because at the end of the day, when we talk about diet, often people have the concept of certain food items, like functional food, or certain food groups they should have more or less of.”

“But it’s really about the dietary factors, so how it differs between people with early-stage cancer and people with advanced cancer. So, during treatment time regardless of whether it is early-stage or advanced, you really want to have a good balanced diet so that you’re, you are getting all the nutrients that body needs to support you to get through the treatments.”

“For people with early-stage cancer, then obviously the focus will be after treatment stage, to have a balanced diet and prevent further weight gain, and to remain within a healthy weight range to reduce the risk of cancer recurrence. Whereas for people with advanced cancer, maybe they are still living with cancer, but it’s still important to maintain a good balanced diet and prevent malnutrition, because there are other aspects and things we need to consider as well.”

“So, in summary, there shouldn’t be any big change between the two. When someone is going through cancer treatment, they may require something different, particularly if they are experiencing some symptoms or other conditions requiring them to restrict certain food or having more of a certain type of food.”

How important is nutrition and exercise for someone who has recieved a breast cancer diagnosis?

“I think it is very important to have a good diet and be physically active, regardless of the stage of cancer. So, we have enough evidence to support the benefits of exercise during treatment, after treatment, even for people living with cancer.”

“We certainly know that a good balanced diet can help and is beneficial during treatments and even after treatments for people with living with cancer. I think that goes hand in hand. It’s not something that you can just do one or the other to get the maximum benefits. Certainly, for some people who cannot perform certain types of exercise, they can only focus on the diet, which is still important.”

“But when we are talking about the maximum benefits, it really comes from a combination of exercise and nutrition.”

What are your hopes for the future of breast cancer research?

“I’m hoping that we’ll be able to get some model of care that provides supportive care to all patients and is sustainable. So, for a lot of the research being done in this space, once the funding ceases, you don’t really see that being translated into clinical practice.”

“So, I’m hoping that there will be some sort of lifestyle intervention support for our patients in clinical setting, not just in the research setting. But I guess it’s important to find out what would be the best intervention for each patient. So, we must go by stages.”

“At the moment I’m hoping that our phase II intervention trial can prove that it’s feasible. And I’m hoping that this sort of similar concept can sustain it and go into phase III and then later in clinical practice.”

“I think my interest in the current area was inspired by occasional women who I was aware who had delayed nausea after their chemotherapy. But in particular I was inspired by my wife, who I was involved in giving chemotherapy to for breast cancer and she had quite profound nausea after her chemotherapy to the point that she was losing weight.”

“We gave her omeprazole and it dramatically improved. So, we started to use that more often, and found benefit with different patients.”

“So, the concept of running a trial to see if that sort of drug could prevent nausea was very attractive. It took some time to set up the study and to get a trainee who would work on the protocol. Eventually that was done, and we had funding from Breast Cancer Trials and the New Zealand Breast Cancer Foundation to set up a randomised study across different centers in New Zealand, to see if we use this drug which lowers acid in the stomach as a means of reducing the nausea, that some women get a number of days after chemotherapy.”

“The reason for developing the trial in this way, not only through anecdotal experience, but we know that chemotherapy and steroids can cause inflammation in mouth, esophagus, and stomach. And if we could reduce that inflammation, maybe we could help with the nausea, as we were seeing in those patients.”

Can you explain a bit about the research behind the PantoCIN trial?

“The research is that there is evidence that the drugs we use to prevent breast cancer, both as chemotherapy and as part of the anti-sickness regimen, namely steroids, can cause that inflammation.”

“And we wanted to see if this drug would prevent the inflammation and subsequent nausea. So, we developed what’s called a randomised double-blind study. We got a pharmaceutical group in Australia to produce a placebo or ‘dummy’ tablet, which looked exactly the same as the pantoprazole, which lowered the acid.”

“And then women were entered into the study after they’d been given information about it and were randomised to receive, during their first lot of chemotherapy, either the pantoprazole, the active drug, and for the second lot, they had the opposite.”

“And then we developed a smartphone app, and women were prompted on day five about what their symptoms were, what nausea they had, whether they’d had any vomiting, any other problems.”

“They filled in a little survey, and if they didn’t have a smartphone, they had a paper questionnaire. So, we could look at how frequently women were getting nausea and what intensity it was. And at the end of those two blocks of chemotherapy, they were asked which cycle they preferred, not knowing what they’d had.”

“And the results were that there was a strong preference for receiving the pantoprazole. So reduced amount of nausea, reduced intensity of nausea, and a strong preference for that treatment.”

What does the future hold for the PantoCIN trial?

“Well, it was designed initially as a phase-two study just to see if there was activity, but I think the evidence from the trial is adequate for people to introduce the drug now. It’s cheap, it has no side effects, no interactions with other drugs, and if you use it to prevent the symptom, it’s much more effective than using it to treat it.”

Are there any dietary considerations that go along with this trial?

“We encourage women to just have a standard healthy diet and eat the foods that they enjoy. One of the dangers of chemotherapy is that up to 50 percent of women who have chemotherapy in this setting put on weight, because they feel more tired. They don’t exercise as much because they’re tired. And they graze eat to try and give themselves an energy boost to get through. And because of this they often put on weight.”

“So we actually had another study in Palmerston North, where we looked at women and we encouraged them to exercise for more than 30 minutes, four times a week, getting their pulse rate up over 100.”

“And having a standard healthy diet, which was recommended, just a standard diet from a dietitian. Nothing exclusive, no additives. And we found that no woman put on more than 100 grams, so there was no weight gain. And I think that the exercise also makes women feel as though they’re doing something active to counteract being poisoned by their treatment, which if you sit there and just take the chemotherapy on board, you feel lousy.”

“If you’re doing something active, you feel a lot better, and you may prevent that additional weight gain, which also makes you feel lousy. Particularly if you’re sort of around menopause time and you’re shoved into menopause, and you have all the additional problems related to that.”

“But I don’t think you need specific dietary alterations or to avoid anything in the short term, but just focus on eating sensibly. And maybe, by preventing your stomach from being inflamed, you can enjoy the food you normally enjoy, rather than being worried about it or bothered by it.”

What are your hopes for the future of breast cancer research?

“Well, it’s still a significant issue, there are still women getting nausea, even though it may be less intense. And I think that there’s potential for further research into that area to see if we can make it even better.”

“I think that there is likely to be a strong anticipatory component. A lot of women go into treatment fearful of having chemotherapy, expecting to feel sick. And if they have a bad experience in that acute first 24 hours, it may take some time to recover.”

“They may be expecting to continue to feel less well for some time. So maybe some psychological intervention may make a difference to that. We know that the mind can have potent effects on different symptoms from placebo effects, and I think there’s a real benefit here.”

“But I also think, perhaps some exploration of other factors, such as anticipation or expectation of nausea would make a difference.”

Professor Sibylle Loibl is the Chair of the German Breast Group and a Professor of obstetrics and gynaecology at the Goethe University of Frankfurt. Professor Loibl was an international guest speaker at the Breast Cancer Trials 44^th Annual Scientific Meeting in Auckland, New Zealand, and we asked her about her research in the area of neoadjuvant treatment for triple negative breast cancer.

“The Breast Cancer Trials conference is obviously very close to my heart because it’s the trials conference, and I’m running a trials group. It’s obvious that we need to exchange across the globe when we run trials together as we learn from each other, and I think that’s the main thing. That’s why I’m here.”

“The keynote presentation I’m giving today is on early triple negative breast cancer and the neoadjuvant treatment in triple negative breast cancer is one of the most important topics, at least to me as well. Not only because it’s relevant for the patients but also because we have recently focused research very much on triple negative breast cancer.”

“Patients have done many analyses in this subgroup and with the germline BRCA carriers coming up, and I think this has a special interest right now in the young women having many triple negative breast cancers. I think this is a very important topic and I’m looking forward to discussing it at the conference.”

Are you looking forward to the Trainee and Early Career Day on Saturday?

“The second topic which I think is important, is the meeting with the young people on Saturday morning at the Trainee and Early Career Day. I’m speaking there about what’s new in early breast cancer. I don’t think it’s very important what I speak about, but I think it’s important to have the interaction with the younger generation, to make them interested in clinical trials and to teach them about clinical trials, and to make them aware.”

“We can only present something or speak about what is new if there was a clinical trial behind what is new. So, I think that’s important in the whole setup of this conference.”

Why is international collaboration so important?

“International collaboration is also important because, the cancer subtypes and the groups are becoming smaller and smaller. We are doing clinical trials and therefore we cannot run several thousand patient trials on our own in one country anymore.”

“So, we need to collaborate, and we especially need to collaborate with other groups across the globe who have similar ideas and have similar setups. And I think that makes it very important to have this exchange. And this is the challenge in running the clinical trials nowadays.”

“I don’t know really where we are going in the future of breast cancer research. I mean, we have a lot of new drugs coming up. We have new sets of drugs, like the antibody drug conjugates, which fascinates people, and they are particularly fascinating because it’s such an intelligent model of delivering a highly toxic drug to the cells to work against the cancer.”

“And I think they work in many cancers, but I also think the immunotherapy will develop further beyond what we are seeing now, and we may even see a vaccination in the future. And I think we still are not there yet. We still don’t have a cure for cancer, and I think curing cancer is the main aim we all have in the end.”

Alastair Thompson is a Professor of Surgery and Associate Director of the Dan L Duncan Comprehensive Cancer Centre at the Baylor College of Medicine in Houston, Texas.

Professor Thompson was an international guest speaker at Breast Cancer Trials 44th Annual Scientific Meeting in Auckland, New Zealand, and we asked him about his research in the areas of DCIS, Neoadjuvant chemotherapy, and postoperative recovery.

“So, the Breast Cancer Trials conference is a really exciting annual event. I think it’s a huge privilege to be invited to come here and to share some thoughts and ideas, and also listen to the wisdom that’s emerging from New Zealand and Australia.”

“International collaboration in breast cancer is essential if we’re going to address some of the continuing and ongoing problems that women and men face with breast cancer. And the ways we’re going to do that, and are doing that, is to work together so that when we design clinical trials, that we work across the world to implement those trials.”

“So the topics that I’m going to be talking about range from DCIS, which is pre-invasive malignancy of the breast, where we still don’t know how to stop over treating patients, and there are a number of trials going on around the world, which I’m going to allude to and mention, that I think are going to change practice in the next 2, 5, and 10 years.”

“And then at the other extreme, we have patients who have an invasive cancer in the breast, which we treat with neoadjuvant chemotherapy to shrink and melt the cancer. A conundrum at the moment is that if we are successful, and our medical oncologists shrink the cancer so there’s nothing there, how do we tell there’s nothing there?”

“And if there is nothing left, why are we operating as surgeons? Because the patient doesn’t get a benefit from that surgery. So the big debate, if you like, is are there patients that we can avoid or omit surgery for, after they’ve had their cancer melted by neoadjuvant therapy.”

What are some of the major milestones that have been made in the breast cancer space over the last decade?

“Breast cancer has become a series of niches that we need to address individual problems for individual patients and that needs global intervention with a series of studies trials to try and work out what we can do.”

“Then to reduce that to a patient specific issue of how are we going to do less for some patients who don’t need the treatments and how are we going to target the more aggressive, nastier cancers and get rid of them as well if we’re going to achieve what I think we can do, which is to improve our breast cancer survival and the quality of life.”

Professor Philip Poortmans is a Radiation Oncologist at the University of Antwerp in Belgium. He completed his medical studies at the university and was trained as a Radiation Oncologist at the Middelheim and Vincentius hospitals in Antwerp.

Professor Poortmans was an international guest speaker at the Breast Cancer Trials 44th Annual Scientific Meeting in Auckland, New Zealand, and we asked him about his research in the area of axillary management.

“I’m Philip Poortmans and I consider myself rather as a breast cancer specialist with radiation oncology as well. I’m a true European, I’ve always lived in Belgium, did my training in Belgium, worked at two different places in the Netherlands, followed by three years in Paris, France.”

“And now I’m back close to my home in Antwerp in the north of Belgium. I love going to scientific meetings, whether they are educational or research oriented or more general. As long as the main topic is breast cancer because that’s really what interests me more.”

“The reason for going to meetings is a manifold. I love to share my experience and my knowledge, but I also like to absorb and to learn from others. And the social interaction between all healthcare professionals and the patients as well is so enriching that it cannot be replaced by what we witnessed during the COVID pandemics area in the virtual world.”

“We need to get together. We need to look in each other’s eyes and to speak live. And also of course, there is always a life in between the sessions during the breaks after the sessions. And this is so enriching. It’s a real way forward to build relations and to do the things together.”

What are some of the major milestones that have been made in the breast cancer space over the last decade?

“We learned over the last few decades that there is not one type of breast cancer. Breast cancer is a hugely variable disease with a lot of expressions. We call it the molecular subtypes, but you also have the stage, and you have the population in which the breast cancer is detected and treated. However, there are a lot of common grounds, and therefore we need to collaborate internationally.”

“A lot is similar, independent of where in the globe you are, or the patient is located and treated. That’s why we need to do the things together. Currently, performing clinical research is hugely complex because of a lot of reasons. It concerns privacy, insurance, administration, and all of that requires a huge amount of money, especially for having high-quality research, and a high level of evidence to back our research.”

“We also often need a large number of patients, or we need to do trials in a very small subgroup of the breast cancer patients. And these are all reasons that we need to do it together. We cannot do it in one country and then expect that other countries in another place of the world will simply adapt.”

“It has to be validated. Let’s work together for now and for the future of our patients. I’m very happy to come here because I had quite a few contributions and I still have some to go. Yesterday we had a session about clinical trials that are being developed currently, and most of them involve all of us.”

“They are multidisciplinary trials, and that’s why I was very happy that I could comment on one specifically. I was invited to give some critical comments on it, but I also could comment on the others. Today I will be speaking about the management of the axilla, and the management of the lymph nodes under the armpit.”

“This is a domain that has seen a huge evolution over the last decades. When I was in training, quite some years ago, treatment was standardised and the same for everybody, a complete surgical axillary clearance. This led to high morbidity, increased the levels of lymphedema of the swollen arm, and for most of the patients, it was absolutely unnecessary.”

“If you do surgery and the nodes are not involved, that’s good news, but you have the side effects. So we learned to do more targeted approaches.”

What will you be discussing at the conference?

“Nowadays In high-risk patients, we give the chemotherapy first and then we proceed to the rest of the treatment of the breast and of the lymph nodes. And this has challenged us to rethink the management of the axilla. And my topic today will be about how to manage the axilla after chemotherapy first, followed by limited surgery of the axilla, and then encountering a node that is involved by tumour, and what to do then.”

“The discussion question, which is valid worldwide, is do we need further surgery, or can we treat the patient just with radiation therapy alone? This is what I will explain later.”

“Tomorrow we will have other topics. And one of the topics is that less and less patients need mastectomy because thanks to screening, we find patients in an earlier stage of their diagnosis. So it can be done with breast conserving therapy. We know this is the preferred approach and patients who have more advanced breast cancer can be treated with chemotherapy, immunotherapy, and other approaches.”

“First the tumour is reduced, and then often they can be treated with breast conserving therapy. Nevertheless, there are some circumstances in which we need a mastectomy anyway. Those patients with the exception of very few, are entitled to a breast reconstruction.”

“And this is challenging, especially if the patients also need radiation therapy. Because it impacts on the complication rates, and it impacts on the cosmetic outcome. And one of the topics which is currently hot, is ‘why not, after the chemotherapy, give the radiation therapy first and then only after the radiation therapy proceed to the mastectomy and to the breast reconstruction?’”

“Already 10 years ago, it was launched that the forecast for the future would be that we can cure all breast cancer patients. The few breast cancer patients that we could not cure yet, should be turned in a chronic disease, which you can live with for decades with a high quality of life.”

“This will stepwise improve further. And this can be done thanks to early detection and screening. But this needs to be more focused. Living in Belgium, I live in the country with the highest rate of breast cancer of the entire world. And there are a number of explanations for that. And the explanations are quite simple, but we cannot solve them. The risk for breast cancer increases if we grow older. And the risk for breast cancer decreases with every pregnancy.”

“The younger the pregnancy, the higher the protective effect. So already 300 years ago, breast cancer was called the nun’s disease, because nuns had no children and lived much longer than the general population.”

“We cannot say, okay, we’re going to lower breast cancer by having a lot of children at a young age. That’s not the way. But we are working, for example, at hormonal interventions that might have an effect similar to the protective effect of a pregnancy. This is one of the things that I think will impact a number of patients. And then the patients who develop breast cancer will be treated much more individualized, much more optimized, not the same approach for all breast cancer patients.”

“It will be more effective for those who need it and less impacting for those who don’t need the intensive treatment. And that will ultimately lead to an even higher proportion than today of patients who survive the breast cancer, but not just survive it, also have a low impact of the burden of the treatments.”

Are you looking forward to the Trainee and Early-Career Day?

“I’m very happy that on Saturday we have a day for the young colleagues. It’s in the morning until the early afternoon session where we will discuss how our professional careers developed. And I’m happy that I can present my personal appreciation and thoughts about mentorship because we can be taught, we can learn, but the teacher is not a mentor for optimal professional development.”

“You need good teachers, but you also need extra guidance and mentorship, which is one of the approaches that is quite successful in that it’s highly demanding. Both from the mentor and the mentee, but it is also improving the satisfaction in your professional career.”

Associate Professor Andrew Redfern is a Medical Oncologist and translational researcher from Western Australia, with a particular interest in understanding why breast cancer treatments may or may not work in certain groups of people. Part of his focus is working with Aboriginal Australians to try and answer this question.

We spoke with Associate Professor Redfern about the importance of addressing adverse breast cancer outcomes in Indigenous Australians.

“So in Aboriginal Australians in Western Australia in particular, breast cancer is less common than the general population and we’ve been looking at some of the reasons for that in addition. The higher mortality rates for Aboriginal Australians, we’ve found partly relate to what has been studied in all the other states, that is that they are at a slightly later stage, meaning larger cancers when they come to medical services.”

“These patients are often also more remote in terms of location and therefore, there is a slight reduction in the comprehensiveness of services available. However, we’ve also looked at the biology of breast cancer in Aboriginal Australians. We’ve looked at the types of cancer they get and how they behave, and we found many differences there also. We found they get more aggressive types of breast cancer and we’ve found they have more vitamin deficiencies that make the cancer more aggressive.”

“We’ve also found that the immune system interacts differently with the cancers and may cause further problems. And so there are many different facets to why there’s a worse outcome, all of which we’re trying to address.”

What is the impact of lower screening rates in these communities?

“Certainly, lower screening rates are a factor in the high mortality for the Aboriginal Australians, but they’re just one factor. We do see that screening rates have been 15 to 20 percent lower over the last 20 years.”

“There has been some success with both the Aboriginal populations, so the screening rates for both have risen, but there’s been this continual gap of about 15% lower in Aboriginal people, and there are efforts going on to try and address that also.”

How is data collected in Australia about breast cancer in Indigenous communities?

“You can work out the kind of cancers and how large they are and how far spread they are from central data. There are many things that are important to survival in Aboriginal Australians that really need you to be on the ground and collecting data from the patient as it develops.”

“There are things like exercise levels and diets which can influence outcomes. And also, the degree to which people are compliant or adherent to their medications. So we’ve seen both in remote populations and in Aboriginal populations that side effects are worse on some of the drugs for breast cancer, and we’re seeing then there’s higher rates of dropping off those drugs, which also will be affecting survival rates.”

“Regarding policy and services for Aboriginal Australians, we’ve found that firstly when you’re giving intravenous treatments like chemotherapies in Western Australia in particular, all of the chemotherapies are given in the lower third of the state. And some people are travelling a couple of thousand kilometres in order to get just one course of chemotherapy for an hour.”

“Regarding the upper two thirds of Western Australia, which is an enormous landmass, we’ve got people travelling two thousand kilometres for a single cycle of chemotherapy. We identified where Aboriginal patients were most clustered and we’ve put in three video chemotherapy services. One is in Broome, one is in Karratha, and then there’s another one in Narrogin, which is a smaller town towards the south of the state.”

“And people can go to those services. We video link the Oncologist to them and they have a talk and discuss any side effects. And then there’s a local chemotherapy nurse who can deliver their treatment and that’s saving them having to travel vast distances.”

“The other thing we’ve got in the works is we’re setting up telephone help services for people on chemotherapy tablets to both manage side effects and to make sure that their prescriptions are up to date and to get those to people to try and get more patients to the end of their tablet treatments and hopefully improve results that way also.”

Is there sufficient information to assist these communities with education about breast cancer?

“It’s certainly for Western Australia in terms of culturally appropriate information. There are now culturally specific information sheets and telephone lines through the Cancer Council in Western Australia, addressing things from the Aboriginal perspective, both about different treatments, such as chemotherapy and radiotherapy, and separate resources for different types of cancer.”

Is there an under representation of Aboriginal and Torres Strait Islanders in the health service?

“Certainly, when we look at Indigenous people working in health services and in science as well, there is a shortage, and we’d like to recruit more people. We in fact have a position for an Indigenous healthcare worker looking at expanding these services to remote areas and we’re still looking to recruit somebody after over a year now.”

“So, it is something that there’s a short supply of. We do now have contacts in each of the states, though, and we have three scientists, all of whom have indigenous heritage also working in the area, as well as two people in the medical service side.”

“I think it’s quite easy to overlook things when we make a lot of assumptions. We assume similarities when sometimes there are distant differences. And so, some of these services need to be structured around certain aspects of Indigenous culture. For example, in some Aboriginal communities the Elders set times for men’s and women’s business where men attend to business at certain times of the year and women at certain other times of the year.”

“So, for example, if you have your mammogram van arriving and it’s a time when it’s not women’s business time, then you will likely get a very low uptake. Whereas if you coordinate it appropriately, then you’ll likely find a much-improved uptake.”

How do we address these poorer breast cancer outcomes in Indigenous Australians?

“Well, one of the core things we’re enacting to try and improve the outcomes in the Aboriginal Australians in WA is looking at a centralised kind of advisement service. Each person who gets cancer, when they get their biopsy or their surgery, their specimen goes to a central pathology laboratory, and if the patient identifies as indigenous, then that information goes with the sample to the cancer registry.”

“And we’re identifying recently diagnosed Aboriginal people, and we have central discussions of cases with a panel of experts, including people with Indigenous cultural expertise. And then we liaise with each person’s local treatment team to try and devise the best plan, both with the information we’ve already learned from our research and with further cultural input from experts in that field.”

“Certainly, regarding clinical trials, there does appear to be a lower rate of recruitment from the Aboriginal population, because the rates of people are low and there’s a very large sector of the community that is remote. So, there’s a lot of the things we can do to address Aboriginal trial recruitment, and a lot would be dealt with by addressing geographical recruitment.”

“However, also it’s important to have culturally appropriate materials to explain trials. And though we have materials on trials in general, we don’t have anything yet for Aboriginal or other Indigenous peoples. When we look at the types of cancers Aboriginal people are being diagnosed with in Western Australia, we suspect it’s due to the difference in risk factors, in the Aboriginal population compared to the non-Aboriginal population.”

“In particular they have more aggressive cancers as obesity is somewhat higher and there is a higher level of alcohol consumption. There are also lower vitamin D levels in Aboriginal patients, and that can drive aggressive types of breast cancer also.”

“There is also a lack of risk factors for the better prognosis cancers, the hormone driven ones. As Aboriginal women tend to have more children, they have their children earlier, they’re more likely to breastfeed, and they’re less likely to use oral contraceptives and hormone replacement therapy. So, part of it may be that they’re just getting less low risk cancers, which makes the high-risk cancers a bigger proportion.”

“Regarding the bigger tumour size that we see in Aboriginal women, I think this is due to two factors here. There is the fact that screening is lower and so patients are likely coming at a slightly later stage, with their tumours. But also, these more aggressive types of cancer we’re seeing in the Aboriginal people grow faster. So, when we look at all types of people, we find that these aggressive cancers tend to be larger than the lower risk types and so that’s likely a factor also.”