Dr Laura Esserman Of The San Francisco School of Medicine On The 5 Things Everyone Needs To Know About Cancer
An Interview With Savio P. Clemente
Cancer survivors may experience worry, fear of recurrence, or periods of depression once treatment has ended. It can be difficult to resume normal life activities after such an experience, so I encourage my patients to lean on family and friends for emotional support and also look for resources in their communities to help make this adjustment. There are often good programs and places where they can seek professional help and support groups — many programs are even accessible virtually now, thanks to effects of COVID-19. We must also remember that cancer doesn’t only affect the patient; it affects the family, loved ones and caregivers as well. It is so important for support to continue well after treatment.
Cancer is a horrible and terrifying disease. There is so much great information out there, but sometimes it is very difficult to filter out the noise. What causes cancer? Can it be prevented? How do you detect it? What are the odds of survival today? What are the different forms of cancer? What are the best treatments? And what is the best way to support someone impacted by cancer?
In this interview series called, “5 Things Everyone Needs To Know About Cancer” we are talking to experts about cancer such as oncologists, researchers, and medical directors to address these questions. As a part of this interview series, I had the pleasure of interviewing Laura Esserman.
Laura Esserman is a surgeon and breast cancer oncology specialist. She is the director of the Carol Franc Buck Breast Care Center at the University of California, San Francisco School of Medicine. She leads the I-SPY trials, Athena Breast Health Network and the WISDOM study. She has also taken these lessons to help her critical care colleagues run the I-SPY COVID trial for critically ill people with COVID.
Thank you so much for joining us in this interview series! Before we dive into the main focus of our interview, our readers would love to “get to know you” a bit better. Can you tell us a little something about your childhood backstory?
I was always an energetic and enthusiastic child who took great interest in all things, especially science and theater. I’m the youngest of four children; I have one older brother and two older sisters. I was born in Chicago at Ingalls Memorial Hospital, and then moved to Miami with my family when I was about nine or ten years old until I relocated to Boston for college, and then moved West for Stanford medical school.
For the benefit of our readers, can you give us an idea of how you got to be such a leading voice in the cancer arena?
I’m a surgeon and breast cancer oncology specialist practicing at the UCSF Carol Franc Buck Breast Care Center, where I’ve held the position of Director since 1996. I also co-lead the Breast Oncology Program, the largest of the UCSF Helen Diller Comprehensive Cancer Center’s multidisciplinary programs. As a professor of Surgery & Radiology at UCSF, I have spent my career studying breast cancer and researching ways to improve treatment at the earliest as well as locally advanced stages of care, with an eye to cancer prevention. As part of this program, my research has also focused on how to make clinical studies more inclusive, more efficient, and more relevant to the questions that my patients care about most. I’ve also focused on bioinformatics, medical and clinical informatics, systems integration and clinical care delivery.
What or who inspired you to pursue your career? We’d love to hear the story.
I’m very fortunate to have many people in my life who inspired me as a child, and who continue to inspire me now. My parents were enormously bright and curious individuals who took an interest in the world we live in, our community and politics. They encouraged all four of us to follow our passions and focus on ways that we could benefit our community. Our shared interest in creating a better and healthier world for women eventually led all of my siblings to find careers within the women’s health sector; my older sister Lisa recently retired from an outstanding career as a breast radiologist, my brother is a practicing OB-GYN, and my older sister Susan is an international trade lawyer who has started a SAFE center at the University of Maryland to help victims of sexual trafficking to transition. Over the years, my siblings, my husband and two children remain my main sources of strength and inspiration.
In medical school, I was particularly fortunate during my research years to study under Dr. Ron Levy, who was a pioneer in monoclonal antibodies therapy and the study of malignant lymphoma. As a clinical research fellow in engineering and economic systems, I collaborated with Dr. David Eddy who developed biological models of cancer screening. Many other colleagues I’ve met along the way, including Dr. John Collins, the chair of surgery at Stanford Medical Center where I trained, Dr. Hailie Debas, Dean of UCSF, and Dr. Nancy Ascher, organ transplant surgeon and chair of surgery at UCSF Health, have also been great influences on my life and career. In the work that I do today, I am incredibly lucky to work with a large network of physicians and scientists of every discipline that challenge and inspire me. Together we are making advances and changes that will make women’s lives better.
Additionally, the patients whom I serve inspire me every day to make sure that we have better health options for tomorrow.
This is not easy work. What most motivates you every day?
My primary motivation behind the work that I do is my patients — each of whom have two things in common: they all want to receive the best treatment available for their diagnosis; and they are all dedicated to contributing to the research that makes such stunning medical advancements as we are seeing now possible.
Specifically, the career I’ve chosen has allowed me to focus on the science of breast cancer and how we can continue to improve and integrate every aspect of care — from policy to screening, prevention and treatment, all to create a system that delivers tomorrow’s care today.
What are some of the most interesting or exciting projects you are working on now?
The two main programs I’m working on are the I-SPY 2 trial and the WISDOM Study (Women Informed to Screen Depending On Measures of risk study).
The I-SPY 1 trial began in the early 2000s and has since evolved into I-SPY 2, a trial for women with what is considered molecularly high-risk breast cancer (i.e., stage II or III breast cancer). Our goal is to find the right drug and give it at the right time to the right patient to prevent women from getting metastatic disease. The I-SPY 2 study analyzes the biology of a tumor and patient prognosis to determine how well the tumor responds to therapies, such as chemotherapy, radiation therapy or hormone therapy, which are commonly used prior to cancer surgery to reduce the size of a tumor and allow for less invasive, breast conserving surgery.
Dr. Nola Hylton and Dr. Laura J. van ‘t Veer are two of the many I-SPY investigators whose expertise has contributed to the research. I’ve worked with Dr. Hylton, an internationally renowned leader in the field of breast MRI, who developed the sequences for breast MRIs and use these imaging tools as a catalyst to change the way we think about therapy, and to shrink tumors and understand who is and who is not responding. Dr. van ‘t Veer, an internationally recognized Molecular Biologist and the inventor of MammaPrint®, an advanced breast cancer genomic test, works with her team to use this trial platform as the premier way to identify markers of response that can be used to facilitate the switching of patients to other drugs when one is not working.
The WISDOM Study is a national study that was launched in 2016 to help determine the safest and best way to screen women for breast cancer by comparing two clinically approved screening approaches: annual mammograms; or a personalized screening approach based on a woman’s individual risk factors for breast cancer, such as breast density, genes, and family history — to finally answer the question: “How do we improve breast cancer screening so less women have to die from this disease?” We currently have more than 35,000 women enrolled in the study with the ultimate goal of enrolling 100,000 women across the nation. The WISDOM Study is committed to enrolling women of diverse backgrounds so that we can help uncover who is most at risk and for what types of breast cancers, because we know women’s risk varies widely based on a number of factors. For example, African American women are twice as likely to be diagnosed with aggressive triple-negative breast cancer when compared to white women and face a higher mortality rate than any other race. While it is uncommon to be diagnosed with triple-negative breast cancer in one’s lifetime, it’s important that our studies are inclusive of all populations, because what we learn today will help everybody as we move forward. If we can begin to figure out who’s at higher risk for these forms of aggressive cancers, including hormone driven cancers, not only can we screen better and more appropriately, but we can also start thinking about how to improve our approach to prevention.
Ok, thank you for all of that interesting information. Let’s now shift to further refining some basic definitions, so that we are all on the same page. What, exactly, is cancer?
Cancer is generally defined as a disease in which some of the body’s cells grow uncontrollably and can spread to other parts of the body; also known as metastatic cancer. However, cancer is not one disease. There are many different types of cancer. Some grow very slowly and are not life threatening. Some can be very aggressive. Nearly everyone is immediately alarmed once they hear the word “cancer,” because they think of fast growing, fatal cancers. However, not all cancers are life threatening. Consider ductal carcinoma in situ of the breast, for example, or some types of prostate cancer. For those conditions, instead of referring to them as cancers, what if they were referred to as “risk factors” for cancer? I think we do a disservice by taking this large range of conditions and classifying them all under the same umbrella term. I’m confident that within the next five years the way cancers are characterized will evolve to the extent that we are more able to easily identify patients who have a condition that requires minimal treatment versus those whose diagnosis requires more aggressive, and I am certain that we will have many more targeted therapies. The need for this vital information is, of course, crucial for the breast cancer community, but also lung, prostate and other cancer communities.
What causes cancer?
The body is always replenishing its cells, so they grow and divide all the time, more in some organs than others. Cancer arises when cells divide and an error allows the cells to grow and bypass the usual controls that keeps them in check. There are a number of risk factors, including the genes you inherit as well as certain exposures. What you eat, how much you exercise, how much alcohol you consume, whether you smoke- all of these can contribute to your risk for cancer. Certain inherited genetic mutations such as BRCA1 or BRCA2 can also increase your risk to develop cancer at an early age, as these conditions indicate that a person was born with pre-dispositions to certain cancers.
Like all cancers, breast cancer presents in so many different ways. How do researchers and clinicians distinguish between the different forms?
Doctors can analyze a tissue sample from the breast, either a core biopsy or tissue from surgery to determine what type of cancer you have. The options for care will also depend on how big the tumor is and its biology. Doctors also look for how different your individual cancer cells appear from normal cells to determine your cancer’s grade. Breast cancers are graded on a scale from 1–3 (this is different than cancer stages), with grade 3 cancers being the most different looking and considered the most aggressive. A lower grade typically indicates that the cancer is slow-growing and less likely to spread. Cells that grow quickly are more likely to respond to chemotherapy and this will reduce the risk of death. Slower growing cancers are less likely to respond to chemotherapy and are often best treated with hormonally based treatments. Certain types of tumors have a marker called Her2, for which there are targeted treatments that have improved outcomes. There are also treatments that target the immune system which have become standard of care for triple negative cancers. It’s very exciting to see all the new therapies that have recently been approved or that are being tested in clinical trials.
I know that the next few questions are vast and complex, but we’d love to hear your thoughts.
For example, to-date how best can cancer be prevented?
What we currently know about cancer prevention is constantly evolving, but there are lifestyle changes you can adopt to help reduce your chances of developing the disease. Following these suggestions are not a guarantee that you will never get cancer, but they help lower your chance of getting cancer.
These include, but are not limited to:
- Eat a healthy diet. This means consuming plenty of fruits and vegetables. Try to base your diet on fruits, vegetables and other foods from plant sources — such as whole grains and beans.
- Stay active. Regular exercise and maintaining a healthy weight might lower the risk of various types of cancer, including cancers of the breast, prostate, lung, colon and kidney.
- Moderate alcohol intake. The risk of various types of cancer increases with the amount of alcohol you consume and the length of time you’ve been drinking regularly.
It’s also essential to encourage healthy habits very early on in life; young children should start early with daily exercise that will help them maintain a healthy weight and can prove effective in preventing all kinds of diseases, not just cancer, later in life.
For some women at higher risk of breast cancer, there are medications that are approved for prevention. These can substantially reduce the risk of getting cancer, just like statins can reduce the risk of fatal heart disease or a stroke.
How can one detect the main types of breast cancer?
There are two primary ways that people present with breast cancer — via mammogram or if there is a palpable mass in the breast. If you have a mass in your breast that is new, you should bring it to the attention of a physician. Even if you’ve had a normal mammogram recently, you should not ignore a new mass in the breast. It’s common for women who get mammograms regularly to be told to return for additional imaging and possibly a biopsy. Fortunately, about 80% of breast biopsies performed are not breast cancer.
If a person receives a breast cancer diagnosis, the medical team must answer several key questions to determine the order of therapy: first, whether it is precancer (stage 0 or in situ disease); if it is invasive cancer; then determine the type of tumor, which includes understanding what is on the cell surface of the tumor cells (receptors). A detailed analysis, called a molecular profile, provides us insight on tumor behavior and what treatments will be best. We also need to determine the size (based on both exam and imaging) and the extent — meaning where else it may be in the body (for example, in the lymph nodes). If the tumor is aggressive and I know that chemotherapy is going to be an important part of treatment, I prefer to administer it first (we call that neoadjuvant therapy), so that I can assess how the individual’s body responds to medication and how much the tumor shrinks. This is crucial information as it determines next steps of care
Before so many advances in cancer care, a diagnosis was tantamount to a death sentence. Presently, what are the odds of surviving cancer?
We’ve seen extraordinary progress over the years in cancer research and treatments that has resulted in increased survival rates for all forms of cancer; it doesn’t have to be the death sentence it once was. Importantly, we have learned that not all cancers carry the same risk. Some have ultralow risk. These cancers have always existed, but they are more common now that screening is widespread because they are easier to detect with screening. For cancers that are more life threatening, breakthroughs in therapy are happening faster than ever — it’s imperative that patients know that there are new options and that clinical studies can represent an opportunity to get better care. All patients must be their own best advocate and explore every aspect of their proposed course of treatment with their medical team. I have witnessed many patients who joined clinical trials and gained access to experimental therapies that resulted in great outcomes. Those patients have been able to resume normal life, even with an advanced diagnosis.
Can you share some of the most cutting-edge treatments for cancer that have you most excited?
I’m particularly excited to see the development of immune-targeted therapies, as they are making a significant difference in those who have been diagnosed with some of the most aggressive forms of cancer. The FDA just approved a combination therapy that includes immunotherapy for women with stage 2 and higher triple negative disease. Another exciting type of treatment, antibody drug conjugates, a class of biopharmaceutical drugs designed as a targeted therapy for treating cancer, are poised to make a big difference over the next decade. These drugs work by binding only to specific cells (hopefully just the tumor cells) and then they deliver their toxin. This makes the treatments “targeted” and less toxic. A couple of these are already on the market, but all have to be tested and carefully evaluated before they are approved by the FDA. I’m so pleased and hopeful that we’re creating room for more drugs like these to come forward that will produce better and better outcomes for patients — with less toxicity.
From your experience, what are a few of the best ways to support a loved one, friend, or colleague who is impacted by cancer? What have you found to be most beneficial in best assisting a patient during the healing process?
Newly diagnosed cancer patients often find their minds buzzing with a million questions before an appointment with their oncologist, especially that momentous first meeting. As patients start to learn more about their options for treatment, the new information they receive from their oncology team, and perhaps their own research, can lead to a sense of being overwhelmed. I’ve found that patients appreciate having a loved one accompany them to some or all doctor visits to listen and take notes during discussions that take place with the oncology team.
Patients should come prepared to ask the questions they’re most concerned about, so that they can walk away from each appointment feeling empowered with the information they need to make decisions about their treatment and feel good about their decisions. To help prepare for these encounters, along with one of my colleagues, we developed a Consultation Planning program — called the Patient Support Core. Our team of research assistants help patients ready themselves for their doctor visits by helping them to generate key questions and concerns, record the conversation with their doctors, and take notes for them. This has proven to be extremely helpful to patients.
Right after a diagnosis, it is good to remind people that they will not always feel the way they do at that moment. Things will get better. Once the initial panic has subsided, they will be able to think more clearly and make better decisions. Cancer is not an emergency, but it can feel like one. Another way that friends and family can show support is by bringing their loved one to treatments, spend time together, and find ways to celebrate the small things. I’ve seen that make a world of difference.
Life after surviving cancer also has its challenges. Although the treatments have ended, the persistent fear of cancer recurrence still lingers with many survivors. Unfortunately, medical professionals can’t promise patients their cancer won’t return or spread to another part of their body, but these concerns must be addressed to move forward. Some people perceive cancer as a turning point and find their life more meaningful. For those whose fear of recurrence is overwhelming, I encourage them to seek individual and family counseling.
What are a few of the biggest misconceptions and myths out there about fighting cancer that you would like to dispel?
Many people incorrectly believe that those with cancer somehow deserve it as a consequence of poor lifestyle choices or their own negative behavior. The truth is, one can make all the right decisions and lead an overall healthy lifestyle, and still be diagnosed with cancer. On the other hand, one can make all the wrong decisions and never develop cancer. Cancer is not a punishment for a poor lifestyle, though as we’ve noted, there are many steps one can take to reduce your risk.
Another widespread misconception is that everyone diagnosed with cancer must seek treatment. Upon hearing the word “cancer,” people are terrified and want to immediately spring into action to rid their body of the cancer. However, certain cancers, like some in the prostate, breast, and thyroid, can carry a very low-risk and not cause a person any serious harm. Prostate cancer treatments have led the way for active surveillance. For patients with a slow-growing prostate cancer, for example, the best option might be to wait and monitor the tumor for any growth instead of seeking surgical treatment. All of this depends on the tumor type. Studies have shown that the word “cancer” has a direct influence on a patient’s decision to seek treatment following diagnosis. There is a community of physician scientists working to better redefine “cancer” so that we do not inadvertently cause fear and anxiety when it is not warranted, and which can result in overtreatment for some.
Thank you so much for all of that. Here is the main question of our interview: based on your experiences and knowledge, what are your “5 Things Everyone Needs To Know About Cancer?” Please share a story or example for each.
- Cancer isn’t one disease — it encompasses more than 200 diseases, and I can’t stress enough how important it is to determine what type you have before making treatment decisions. Find out if there are ways to profile your tumor with a molecular or multigene test and learn whether you have an inherited predisposition by completing a genetic test. For breast cancer, knowing about whether you have inherited a gene mutation can affect surgery and treatment options.
- Advancements in cancer treatment over the past two decades, particularly in targeted treatments and improved supportive therapies, indicate promising results for future cancer patients. Treatments have become more tailored to the individual’s situation; thus, it is crucial to collaborate with the medical team and research the many options available to determine what might be the best course for your type of cancer.
- Contrary to popular belief, cancer is not an emergency that needs to be tended to the moment it’s discovered. After a cancer diagnosis, it’s normal to feel scared, anxious and have the desire to jump into treatment before taking the time to learn your options. Allow yourself and your healthcare team time to learn the biology of the tumor so that it can be a truly collaborative effort.
- If you’re seeking treatment for cancer, you should consider joining a clinical trial, because patients who participate in cancer clinical trials gain access to the most effective therapies currently available. These treatments are potentially even more effective than the current cancer treatment available on the market; many of my patients have had excellent results. This includes women in my active surveillance study for DCIS — today, I saw someone whose imaging was normal after 6 months of endocrine therapy, even without surgery. Earlier this week, I saw a woman participating in the I-SPY TRIAL who had a great response to the first 12 weeks of treatment and whose tumor had shrunk completely, so she was able to skip the more toxic part of the chemotherapy (Adriamycin). African American women have a higher risk of developing triple-negative breast cancer but are less often included in clinical trials where major improvements in response to therapy have been seen. Doctors need to also be more diligent about introducing clinical trials to their patients of all backgrounds and ethnicities, but it’s important for patients to know that it is their right to participate in a clinical trial. For example, in California, there is a bill called SB37 (introduced by then-state senator Jackie Speier) that declares that all institutions and insurers have to cover standard of care costs for people who want to participate in a trial. This opens up access to trials for everyone.
- Cancer survivors may experience worry, fear of recurrence, or periods of depression once treatment has ended. It can be difficult to resume normal life activities after such an experience, so I encourage my patients to lean on family and friends for emotional support and also look for resources in their communities to help make this adjustment. There are often good programs and places where they can seek professional help and support groups — many programs are even accessible virtually now, thanks to effects of COVID-19. We must also remember that cancer doesn’t only affect the patient; it affects the family, loved ones and caregivers as well. It is so important for support to continue well after treatment.
You are a person of great influence in the field of breast cancer. If you could start a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger. :-)
I helped to lead a movement in 2016 and am currently a principal investigator for the WISDOM Study, a clinical study designed to start with risk assessment for every woman and tailor screening and prevention accordingly. We are seeking enrollment of 100,000 women across the nation from diverse backgrounds and ethnicities to determine the safest and best way to screen for breast cancer by comparing two accepted screening approaches: annual mammograms or a personalized screening approach based on a woman’s individual risk factors for breast cancer, such as breast density, genes, and family history. Participants in the personalized arm will have an opportunity to gain access to advanced genetic testing that is not yet available in medical offices.
To date, more than 40,000 women have joined the movement and our goal is to double enrollment in 2022. We want to know if we can make screening just as safe and more effective if we base it on an individual’s risk. But most important, we want to learn who is at risk for what type of cancer, and how to identify the groups of women at risk for the most aggressive cancers in order to find better ways to screen and prevent breast cancer.
How can our readers further follow your work online?
To read my latest articles, visit: https://www.linkedin.com/in/laura-esserman-97b77484/
To learn more about the WISDOM Study, visit: https://www.thewisdomstudy.org
To learn more about the I-SPY Trial, visit: https://www.ispytrials.org/
This was very inspiring. Thank you so much for joining us!