The Science of Happy

One of the best gifts I ever received was from a colleague who sent me a link to this Shawn Achor  TED talk and a small “Gratitude Journal”. This talk, followed by subsequent observations in my own practice, really had me thinking about the impact of our mood on our health. Dr. Achor is a Harvard scientist whose research is focused on happiness. The basic premise of his research findings are two key points:

  • Our brains work more successfully when we are positive.
  • There are ways to train your brain to become more positive.
    • One way to do this is to write down three things you are grateful for, everyday; if you do this 2 minutes a day, for 21-days in a row, Achor reports that the “brain retains a pattern of scanning the world for the positive.”

I used to think that there were happy people in the world (optimists) and there were the others…you know who you are (me, before watching this TED talk).  Dr. Achor’s research flies in the face of this assumption and demonstrates that people are able to impact their level of happiness by focusing on positive things in their life.

I see the impact of mood on health play out on a daily basis in my breast cancer patients. Patients who come in “ready for the fight” tend to do fairly well throughout therapy and those with more fear, not infrequently, had a more complicated or difficult course. That’s not to say there are not genetic or other reasons why some people tolerate therapies better than others. There absolutely are. However, if you look at patients on treatment as a whole, I would say that the optimists tend to do a bit better.

Perhaps this is because the optimists see the chemotherapy as a challenge, something they can overcome rather than a barrier to their well-being. Perhaps the fear and anxiety frequently associated with the diagnosis of breast cancer actually contributes to increased side effects on therapy. There was an interesting study by Cimprich and colleagues reported at the San Antonio Breast Cancer Symposium in 2012  on the effects of mood, specifically anxiety, and fatigue on the development of “chemobrain” or cognitive dysfunction during and following a course of chemotherapy. The study essentially showed that women who were more anxious before starting therapy developed more fatigue and cognitive issues while on therapy. These changes were quantifiable on cognitive testing and on brain MRI. It was pretty impressive to see this direct impact of mood on actual physiologic changes in the brain. What we learned from this study is that really focusing on the psychological state before one embarks on a course of therapy for breast cancer is essential to one’s well-being during and following the course of therapy.

Let me be clear, what I am not saying is, “you were just diagnosed with breast cancer, now be happy!” What I am saying is that once the initial shock of the diagnosis has passed, having some positive thoughts might go a long way to improve your emotional and physical health while on therapy. Positivity can come from appreciating your support system, your care team, or most importantly, appreciating yourself and understanding that you are strong enough to do this.

Strength and positivity can also come from empowerment. Studies have demonstrated that women who are prepared for their consultations with medical specialists by having either a “prompt-sheet” (set of questions for their doctor) or a Consultation Planning session, much like we do here at Breast Cancer Consultants, have a better sense of satisfaction with their subsequent visits with specialists. Controlling some of the “fear of the unknown” with knowledge can be very powerful and may even lead to better well-being during and after breast cancer therapy.

So, if you’re ready to study the Science of Happy, here’s some homework you can do:

  • If you haven’t already, watch Dr. Achor’s TED talk. I still do, frequently…
  • Empower yourself by being prepared for your doctor’s visits.
  • Get a gratitude journal and start writing. It may be one of the best things you can do for your health!


Progress in hormone receptor positive breast cancer, at a price.

In my 10 years as a breast cancer specialist, I have to say that hands-down the most significant progress we have seen in breast cancer therapy has occurred in women with Her2 positive disease, about 20% of the breast cancer population. In fact, a recent 10 year follow up study of one of the trials that led to trastuzumab’s (Herceptin) approval in 2005 demonstrated a near 10% improvement in overall survival (84% survival at 10 years compared to 75%) in those women receiving trastuzumab along with chemotherapy compared to women receiving chemotherapy alone. That’s a lot of lives saved in a 10-year period! These numbers will surely continue to improve with the wealth of new agents developed to overcome trastuzumab resistance in the Her2 positive patient population.

 I am now pleased to say that the same progress is coming to other breast cancer subtypes, as scientists are beginning to understand the pathways of resistance to standard therapies, including the commonly used hormonal therapies (i.e. tamoxifen and aromatase inhibitors such as anastrozole, letrozole and exemestane). This resistance is felt to be one of the reasons that some women with hormone receptor positive breast cancer end up having their breast cancer come back as much as 5, 10, or even up to 20 years after their initial diagnosis.

One such triumph in overcoming endocrine resistance is the development of a drug called palbociclib (to be marketed as Ibrance). The FDA recently announced its approval of palbociclib for treating postmenopausal women with hormone receptor positive advanced breast cancer.  The initial data, presented at the San Antonio Breast Symposium in December 2012, really knocked the socks off the breast cancer specialist medical community, including myself, as we have not seen such results since the advent of trastuzumab, detailed above. This data and subsequent follow up of the women on this trial, led to the approval of palbociclib in combination with letrozole for the treatment of postmenopausal women with hormone receptor positive, advanced breast cancer (i.e. Stage IV, metastatic) as first-line endocrine-based therapy.

 So, what do we know about palbociclib?

  • Palbociclib is part of a class of drugs that inhibits cyclin-dependent kinases (CDKs) 4 and 6. These kinases help facilitate cancer cell growth. Inhibiting them slows growth.
  • Palbociclib is taken orally.
  • It seems to be very well tolerated, with the following being the most common side effects:
    • Lowering of the white blood cells, without an increased rate of fevers or infections.
    • Fatigue

 The Phase II study, PALOMA-1, which led to palbociclib’s FDA approval, included 165 women with hormone receptor positive, Her2 negative, advanced breast cancer. These women were randomized to receive either letrozole (an aromatase inhibitor) or letrozole + palbociclib as their first endocrine-based therapy at the time they were diagnosed with metastatic disease (Stage IV disease). The results showed that women receiving palbociclib along with letrozole on average lived 20.2 months without progression of their disease, compared to 10.2 months for women on letrozole alone. It essentially doubled the time to progression! This was such a significant finding that the FDA decided to grant palbociclib accelerated approval, meaning the drug is now available. However, continued confirmatory studies will determine if it remains available for this indication.

This promising study has led to the development of several larger (Phase III) studies in advanced breast cancer and in earlier stage breast cancer as well. In addition, palbociclib is just one of several drugs and classes of drugs in development to address the problem of endocrine therapy resistance.

So, what’s the downside? Well, as usual, everything comes with its price. The Associated Press reported on February 3, 2015 that Pfizer said it would price palbociclib at $9850 for a month-long course of drug, totaling over $118K per year. Pfizer was quick to mention that this price is not the cost that most patients or payors pay, after discounts to health plans are negotiated. While we know that there is a lot of money invested in the development of a blockbuster drug, some of these costs will need to be addressed as these new classes of drugs might become the new standard of care for women with early and late stage hormone receptor positive breast cancer in the next 5 years or so. That’s a huge percentage of the breast cancer population (about 2 out of 3), and, cumulatively, a huge financial commitment for the breast cancer community.

That being said, the progress that is being made in breast cancer, specifically in targeted therapies for breast cancer, is incredibly exciting. These targeted therapies are minimizing side effects and maximizing efficacy. Ultimately, this progress will result not only in improved longevity, but also an improved quality of life for our breast cancer survivors. Priceless.

San Antonio Breast Cancer Symposium 2014, Day 3

This day consisted of a review of the important endocrine (hormonal) therapy data that was presented the day before. This laid the groundwork for new guidelines to be put in place regarding the treatment of hormone receptor positive breast cancer patients. The long and short of it was really that options for endocrine therapy in both pre-and post-menopausal women need to be individualized based on the patient’s age at diagnosis, risk factors for aggressive disease and other medical issues that might make one regimen more favorable over another.

There was also some new data presented regarding the use of a Ductal Carcinoma In Situ (DCIS) Recurrence Score developed by Genomic Health, the company that developed Oncotype DX. The DCIS Score was developed to distinguish patients in the DCIS population who might be at low risk of local recurrence. Based on this better prognosis, they are suggesting that these women may not need radiation after surgery, as is commonly offered to most patients with DCIS. The study looked at 571 women with DCIS who underwent breast-conserving surgery alone over the course of 9 years. The DCIS Score was run on their surgical specimen and was categorized as low, intermediate or high risk. The study found that the DCIS Score was able to predict which groups had a higher risk of local recurrence for DCIS (5.4% for the low risk group, 14.1% for the intermediate group and 13.7% for the high risk group) and for invasive cancer (8.0% for the low risk group, 20.9% for the intermediate group and 15.5% for the high risk group). Interestingly, the DCIS Score was not as good at differentiating intermediate risk from high risk, thus, the company may decide to make the score have either “low” or “high” results, without the intermediate.

Either way, this may be another tool we can use in the future to help minimize exposure of women to unnecessary therapy. However, we are still waiting on important data that includes patients who have been treated with radiation therapy to see if radiation makes a difference in those with low and/or high risk scores. This information is essential for determining if the DCIS Score is not only good at telling us information on prognosis but will also provide information on who benefits from different types of therapy, particularly radiation therapy. Until this data is presented, I believe most breast specialists will not be using this test routinely in practice.

There was a whole lot more interesting data presented at San Antonio this year…to be continued in my newsletter. Please sign up to get all these and more updates via the Contact page.


San Antonio Breast Cancer Symposium 2014, Day 2

Today we shift our focus to premenopausal women with early stage breast cancer. The SOFT trial reported with over 5 years of follow up. This trial randomized early stage breast cancer patients to one of the following for a 5 year course:

Tamoxifen  OR

Tamoxifen + Ovarian suppression OR

Exemestane + Ovarian suppression

Ovarian suppression = either monthly injections, surgical removal or radiation to the ovaries

The main question they were trying to answer in this study was what is the optimal hormonal therapy for premenopausal women with hormone receptor positive breast cancer.

The results were interesting. They found that women with higher risk breast cancer, particularly those who required chemotherapy and regained their periods, benefitted from ovarian suppression. Whereas, those with lower risk tumors, mainly those who did not require chemotherapy, did exceptionally well with tamoxifen alone.

The most striking results were found in patients who were under the age of 35 and required chemotherapy (which was most of that age group). There was a fairly striking benefit of adding ovarian suppression to tamoxifen (11.2% decrease in the risk of breast cancer recurrence) over using tamoxifen alone. Adding ovarian suppression to an aromatase inhibitor offered even more benefit over tamoxifen alone (15.7% decrease in the risk of breast cancer recurrence).

However, the potential side effects are sobering. We worry about the long-term effects of ovarian suppression with regard to sexual dysfunction, mood issues, late cardiac effects including high blood pressure, bone aches, and bone density, especially in this very young patient population. Aromatase inhibitors can exacerbate many of these symptoms and health issues.

So, the hormonal therapy options have become increasingly complicated and our discussions with patients who fit these criteria are likely to get a whole lot more complicated. However, the end goal is to individualize care as much as possible and with this data, we should be able to do this a little better…even if it does mean some more intensive treatment for our young patients.

Side note: All premenopausal women with hormone receptor positive breast cancer should be discussing this data with their medical oncologist. You can reference the SOFT and TEXT trials and ask how these trials will impact your care. Breast Cancer Consultants can also help apply this information specifically to your breast cancer diagnosis and treatment plan.


Musings on a new venture…

Let me start out by saying that this blog is intended to be a place for me to update you on the latest information out there about living well after a diagnosis of breast cancer, including interpretations of information in the lay press and other interesting information I come across that I feel it would be important to post. However, for this one entry, my first, I would like to give you some insight into my journey and why I am so passionate about this new role.

In retrospect, all of this does seem a little cliché. After all, I hit my 40's and all of a sudden here I am in a major career change. But to me, as I reflect on this change now, I see some parallels between the journey of a woman who is newly diagnosed with breast cancer and my own choice to chart a new course for my career. 

Through 9 years of post-graduate training, I had a clear path. I knew where I was supposed to be and what I was supposed to do and what was expected of me. Though very physically and mentally challenging, I felt fortunate that I had a path. When I finally got my first real job at age 31, I was so excited to be doing exactly what I set out to do; treat breast cancer patients. It was very exciting and scary at the same time.

It remained that way for quite some time. However, over time, I began to understand the realities of practicing medicine in the US. The demands of seeing a large volume of patients and trying to deliver the standard of care to which I was accustomed began to be at odds with each other. I became increasingly frustrated. I began contemplating all sorts of crazy career ideas. My mother instilled in me the love of baking pies and at one point I was very close to closing up shop and opening a pie business. Then I realized, those 4 AM mornings were probably not for me.

About a year or so went by with me wondering how best to utilize my skills in a way that will challenge me but will also feel gratifying. I started noticing my patients’ frequent concerns regarding the scheduling, waiting and general inconvenience of traditional medical practices. They would often say, "I love seeing you but I hate waiting in the oncology office". Or, "I love seeing you but the parking here is so expensive, is there anything else we can do?”. I also would frequently get emails and calls from friends or family members about someone they knew who was newly diagnosed with breast cancer, asking if I would be willing to speak with them and give them some guidance.

Then, the light bulb went off. People want timely, accurate and personalized information when going through a medical crisis, like a diagnosis of breast cancer. Why can’t we take away all the barriers to providing this service in a traditional practice and get right to the heart of what’s needed, which happens to be what I love doing…educating and empowering patients and their loved ones to make their own best health decisions?

So here I am, taking a major leap of faith, about to embark on a very new venture and might I add, unchartered territory. I am learning new things on a daily basis and growing in a way that I couldn't have imagined in my previous career. While scary, at the same time I have this incredible sense of calm because I finally have control of my path.

And here's where we come back to the parallel. Though the change is admittedly quite different, we are both looking for the same thing; a sense of control and peace of mind that we are doing the right thing. My work as a breast cancer consultant aims to provide control and empowerment through education and compassion to women who are thrust into a diagnosis of breast cancer. 

Here’s to both of us for finding our way!