Driven to know what drives breast cancer

No person, no disease and no experience of life with breast cancer is the same. No treatment or care plan should therefore be the same. With 25 years of frontline clinical and academic experience anchored at the Memorial Sloan Kettering Cancer Centre, Maura reflects on how research is driving evolution in personalised care and what this means for people with breast cancer.

An interview with Maura Dickler, Vice President, Global Product Development Oncology, Breast and Gynecologic Cancers, Genentech

From bench to bedside and back again

Throughout my career, I strived to combine clinical research with patient care and found it rewarding to be able to offer patients cutting edge treatments as part of clinical trials, particularly as those in trials often face incurable metastatic disease. Clinical research offers the opportunity for individuals to access new medications, often providing much needed hope when facing a troubling diagnosis of cancer.   

In fact, what I love most about Roche is the willingness to learn from the science and from patients - to develop new drugs, test them in rigorous, innovative clinical trials, learn from the data and specimens collected – iterate and try again.

Disease characterisation led the HER2 revolution

I started taking care of people with cancer in the late ‘90s and I remember when the first targeted treatments for people with HER2-positive tumours transformed metastatic breast cancer, thanks to the earlier characterisation of the HER2 protein.

Since then, we have come a long way in the last 20 years with treatment in HER2-positive breast cancer and it is no longer seen as the ‘worst type’ of breast cancer to be diagnosed with. A deep understanding of HER2 disease and its drivers continues to underpin treatment improvements. We can now identify high-risk patients, who show biomarkers for likely recurrence, and those with residual disease at the time of surgery for whom additional therapy could improve outcomes. At the same time, those identified as being at low risk may be spared the toxicity of additional therapies, through de-escalation of treatment. This biological understanding, combined with clinical trial innovation and novel endpoints, means a total transformation of treatment along the disease continuum. 

The work being done within Roche Diagnostics and Foundation Medicine is an enormous part of this effort and has led the way for classifying all types of cancer. Genomic profiling and biomarker analysis have really expanded our opportunities for individualising treatments, and we have a better understanding of the underlying biology and drivers of cancers than ever before. This allows us to tackle multiple tumour types based on drivers of, rather than the location of, disease. It’s an exciting time to be in this field!

What about challenges in other breast cancer subtypes?

Some breast cancers are undeniably difficult-to-treat. Hormone receptor (HR)-positive disease is an area where we know there is real room for improvement. Currently, approximately 50% of people with HR-positive early-stage breast cancer will stop their treatment due to side effects. We are striving to help make the treatment of HR-positive breast cancer more tailored, effective and less debilitating. We are not limiting our work to metastatic disease, instead bringing it forward to earlier stage HR-positive breast cancer, where there hasn't been much innovation in hormone therapy for more than 20 years and where the potential of endocrine therapies, particularly selective estrogen receptor degraders (SERDs) is very exciting.

Triple negative breast cancer (TNBC) is another difficult challenge. There is so much to learn here, and we are actively playing a role in that learning as we recognise this population has often felt left behind. There have been huge innovations in the field of immuno-oncology to help restore a person’s immune system so they can attack their own cancer.

The issue of disparity in breast cancer is important to mention here. I worked at a major cancer centre in New York State and, even within an evolved healthcare system in a metropolitan centre, there was enormous disparity of care. In many ways, this fuelled my strong belief in working to get treatments to all patients. I am now able to educate future generations of oncologists about characterising patients and their disease in a more nuanced way. It’s personalised care coming full circle.

In terms of future trends, the ESR1 mutation is interesting and helps us understand resistance mechanisms in HR-positive breast cancer, and the field of DNA damage response is providing new avenues for disease management.

Breast Cancer Awareness Month (BCAM) – reducing fear, increasing hope

I think that BCAM is incredibly important to reduce fear and to improve access to screening. My hope, honestly, is that, in this month and beyond, more people will do a breast self-exam and that people will be diagnosed earlier, get the right medicine, and potentially be cured. 

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