Once-shunned terms are sneaking into the cancer-fighting lexicon. “Quality of life.” “Survivor.” “Cure.”
Cancer still taunts modern medicine with its erratic behavior and elusive nature. But in our region, these breast cancer physicians and researchers are staring down their nemesis. Many of their patients, they are certain, can not only survive but thrive, managing the effects of treatment while going about their daily lives. There is still a long way to go, they know, but a new era is dawning in breast cancer treatment.
Dr. Elizabeth C. Horenkamp, Lancaster General Health
For Dr. Elizabeth C. Horenkamp, every day is different, and so is every patient. Some are confronting a terminal diagnosis of breast cancer. Others are in early stages, likely to be cured and open to discussing beneficial lifestyle changes.
“Breast cancer is a disease that we generally can treat for years, lots of times, with very good quality of life for a majority of that time, so it allows a lot of getting to know people, a lot of discussions about life goals and what’s important to them as we choose therapies,” says Horenkamp. “That’s really a part of oncology today.”
Horenkamp is a hematology/oncology specialist with Lancaster General Health and, now, a contributor to Penn Medicine research on improving treatments for metastatic breast cancer. Horenkamp “kind of fell into” breast cancer as a specialty early in her career, not long after losing an aunt to metastatic breast cancer and while serving in the U.S. Air Force as the only medical oncologist at a small base.
In those days, doctors had fewer tools to battle breast cancer. They sought effective therapies, regardless of toxicity. In the last decade, the focus has grown on finding “not just effective therapies, but therapies with lower toxicity,” Horenkamp says.
“The cancer survivor phenomenon really wasn’t an issue 20 years ago, but now we have a huge number of survivors, and we’re seeing the side effects of treatments,” she says. “We’re stepping back for targeted therapies, finding treatments that specifically target the tumor but hopefully limit toxicity on normal tissue.”
However, doctors still can’t predict whose breast cancer will recur. The odds of a cure may increase with each treatment option, starting with radiation and surgery and progressing to systemic therapy such as chemotherapy and hormonal therapy, but for whom? Some patients undergoing chemotherapy might not need it, while a small percentage is “100 percent in the group that does recur,” says Horenkamp. In some cases, side effects can be as risky, as with the chemotherapy complication that nearly took the life of broadcaster Robin Roberts.
“There’s only a small proportion of those women whose, quote-unquote, ‘life I’ve saved’ by giving them systemic therapy, and so we have to make sure the rest of the women are not unduly harmed by trying to save that percentage,” says Horenkamp.
Now, Horenkamp is shepherding Lancaster General Health through an arduous approval process to open participation for its patients in a Penn Medicine study researching these questions. Led by Dr. Angela DeMichele, co-leader of the Penn Medicine Breast Cancer Research Program, the study scrutinizes tissue from recurrent tumors to “investigate things we could use to help target therapy,” Horenkamp says. The research is seeking newer markers to help further customize treatment, and it examines “the very important question of why did this patient recur and her neighbor didn’t recur, even if we treated them exactly the same.”
Outside the hospital, Horenkamp spends time with her four children, ages 14 to 21, “whenever possible.” She relaxes by reading and gardening. She counsels regular, moderate exercise—“enough to talk but not sing”—to reduce the chances of first-time and recurring breast cancer, and she practices what she preaches.
“I can’t effectively counsel my patients to exercise if I don’t exercise on a daily basis,” she says.
She’s heartened by medicine’s movement toward “value care, trying to get people more involved in health care decisions.” On the scientific side, Horenkamp sees the beginnings of “getting to the place where we can really know what makes people’s cancers tick.”
“I hope that in 20 years I’m going to have a very engaged patient that I can sit down with, and I show them a profile of their tumor and say, ‘This is your risk of recurrence; these are the drugs we could potentially use to limit your risk of recurrence,’ and then we could decide together and have a very high level of assurance that the treatments we choose are going to not hurt them and are also going to leave them cancer-free going into the future.”
Dr. Vered Stearns, The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Medicine
As a child, Vered Stearns spent “quite a bit of time” in the hospital while her grandfather was being treated for cancer. She was five years old when he died, but those days left her with a lifelong ambition to study medicine. Her interest in genetics and molecular biology led to oncology, where she realized she could “be specialized but also provide primary care to my patients and families.”
“I do feel fortunate,” she says of her roles as clinician, researcher and professor at the Sidney Kimmel Comprehensive Cancer Center with Johns Hopkins Medicine, Baltimore. “I feel that I’m in the right field. I love what I do. I have a very nice balance between different parts of a physician’s position. I see and treat patients, but I also conduct a lot of research, and I also help educate the next generation of physicians.”
Stearns practices “translational” medicine–turning laboratory findings into effective treatments. When she started pursuing breast cancer as a specialty, her mentors convinced her that if she wanted to conduct clinical trials, she also needed to spend time working in a laboratory. It was not what she expected, but she plowed ahead and found she was building a knowledge bank of lab science and “how to bring results from the laboratory to the clinic.”
Stearns sees patients in all stages of breast cancer, sometimes those at high risk.
“Some of the work relates to coming up with better therapies, for example for women with metastatic breast cancer,” she says. “Today, most of them will die of their breast cancer, so we need to do better. We need to help them live longer and maybe even help cure their breast cancer, so a lot of our focus is on new drug development for advanced or metastatic breast cancer.”
While medical science has “come a long way in treatment of early breast cancer,” patients are often overtreated, Stearns says. “We don’t always know whose cancer is most likely to come back or not, so we are relatively aggressive early on.” Patients endure side effects, from “bothersome” to “significant and long-lasting.” And they can’t be sure, based on current medical knowledge of markers in the blood and tumors, whether the treatment is the most effective for their individual cancers.
So Stearns’ research focus boils down to two questions: “First, should we give systemic therapy? And number two, which systemic therapy should we give?” Stearns says.
One current study is asking whether markers in the blood can determine if lumps revealed by mammograms are cancerous. Such a finding could minimize the anxiety that comes with surgical biopsies, which find cancer only one time out of four, Stearns says.
Stearns’ work has taken her all over the world, and that’s fine with her. “I really like exploring other cultures,” she says. “I look forward to seeing more and more of South and Central America.”
The mother of three children, ages 13 to 22, has seen “significant improvements in the treatment of breast cancer” since starting her career. In the near future, she hopes to see “better, more effective therapies that will help us cure the majority if not all tumor types” and personalized treatments “so we’ll not be overtreating patients.”
“What my patients tell me and what I observe makes me work harder on my research side. And when I do the research, I want to bring it as quickly as possible to my patients. One part of my job feeds the other daily.”
Dr. Leah V. Cream, Penn State Cancer Institute
To Dr. Leah V. Cream, cancer patients “are survivors from the day they’re diagnosed.” She should know. The Penn State Cancer Institute oncologist lives with a thyroid cancer diagnosed in 2004 and recurrent in 2010, even while she treats breast cancer patients and participates in research.
As a child, Cream knew she wanted to be an oncologist. After medical school, the native of New Hampshire and Vermont came to Penn State Hershey Medical Center for residency and fellowship in 2000. She stayed to pursue the opportunities offered by a large academic medical center while still living amid the greenery she loves.
With her longevity, “it’s been gratifying to take care of some of the same patients for many years. It’s been a place I’ve stayed because I feel that we’re giving the best possible care to breast cancer patients.”
In oncology today, the goal is “to have people with cancer live as well and as long as possible,” and the odds improve every year, Cream says. One long-term patient living with metastatic breast cancer has had access to new, FDA-approved therapies every time her treatment needs to change.
“I’m really in awe of a lot of my patients who are living with cancer, and you would hardly know,” says Cream. “To see them in the grocery store, you would not realize they are undergoing cancer treatment or have had recurring cancer.”
Cream’s own cancer story begins when her youngest child was eight months old. The biopsy was conducted on a Friday, giving her an anxious weekend to wait for the diagnosis.
“I think that the unknown is the most anxiety-provoking time for patients, going through medical tests and waiting for biopsy results,” she says. “What you don’t know is the scariest, and often what people need most is just a plan.”
Her treatments have included thyroid and lymph node removal, plus radioactive iodine treatment, which targets cancer cells but also requires a week’s quarantine. She spent her quarantine in a New Hampshire cabin.
“It’s nice to have time by myself, but that’s not how I’d like to spend it,” says the blended-family mother of four, who considers humor a powerful tool in her coping toolbox.
Cream is starting a research project testing the effects of exercise on chemotherapy in patients with early-stage breast cancer, in hopes that it “helps the immune system work better and the chemotherapy work better.”
The best part of her job is giving people “good news, that they need less surgery or don’t need chemotherapy,” says Cream. For those who don’t get good news, she has learned “just to listen, especially to patients that often know they’re not going to be cured of their cancer, just to help them have realistic expectations, and to be available to manage all the symptoms and side effects. But often, I feel like I have very little to offer at those times.”
Taking care of cancer patients is so integral to her life, she says, “that I don’t have any times that I’m not thinking about my patients or taking care of my patients. Certainly, I find peace myself by exercising, or being with my children, or working in the garden.”
Cream has explained her own cancer to her children with words of reassurance that don’t conceal the truth. “Kids do figure things out, especially teenagers, so it’s good to be as upfront as possible.”
Cream is enthused about Penn State Cancer Institute’s work improving “the ancillary things” for patients, such as nutrition and counseling. She hopes to see advances against the challenging-to-treat triple negative breast cancer, which often strikes young women. She’d like to stay involved in research “because that’s so exciting and so fun when breakthroughs are made.”
And she’d like to keep taking care of patients, but “maybe not quite so many patients.”
“My wish for my patients and for myself is that cancer is a part of your life, but it doesn’t consume your life, and I think that’s very true of a lot of the patients I take care of.”
