‘Radical’ Explores The Hidden History Of Breast Cancer

IRA FLATOW: This is Science Friday. I’m Ira Flatow. A bit later in the hour, the mysteries uncovered on the surface of a butterfly’s wing. It’s really some interesting stuff. But first, nearly 270,000 women are diagnosed with breast cancer every year, and a couple of thousand men, too. But the disease manifests in many different ways, meaning few patients have the same story to tell.

My next guest collects many of those stories in her book, Radical, the Science, Culture, and History of Breast Cancer in America. And in one of those stories is her own, and she writes, as she writes about her own journey with breast cancer, author Kate Pickert details the history of breast cancer treatment as first devised by a Scottish medical student studying sheep in the 1800s.

That is a really interesting story in the book. Hopefully, we’ll get to talk about it with Kate. And she also chronicles the huge clinical trials for blockbuster drugs in the ’80s and ’90s, one of which required armies of people to harvest timber from the evergreen forests of the Pacific Northwest.

And she writes about current targeted personalized treatments and the surprising East Coast-West Coast divide among breast cancer doctors, each one favoring their own medicine. We’ll talk about all of that and I have a question for you listeners. If you or a loved one have had breast cancer, please share what your experience was like and what you wish you knew before you started treatment.

Our number, 844-724-8255, or you can tweet us @scifri. Also we’re doing a livestream of Science Friday over on our website at sciencefriday.com.

Kate Pickert is former staff writer at Time Magazine, a journalism professor at Loyola Marymount University, and the author of Radical, the Science, Culture, and History of Breast Cancer in America. We have an excerpt from her book on our website at sciencefriday.com/radical. It’s a pleasure to have you on Science Friday, Kate.

KATE PICKERT: Thanks a lot for having me, Ira.

IRA FLATOW: Tell me, what’s the first thing women need to know after they have been diagnosed with breast cancer?

KATE PICKERT: Oh, gosh, there is so much to learn and so little time to learn it. After a woman is diagnosed with breast cancer, in most cases, treatment will commence pretty quickly. So there’s a lot to learn in those first early weeks. I would say the most important thing to know about a breast cancer diagnosis is some specifics about that diagnosis. What type of breast cancer have you been diagnosed with? Because that will drive a lot of the treatment decisions that come on down the line later.

And the advice that I always– I talk to a lot of newly diagnosed breast cancer patients, and I always advise them to get second and third opinions, in part because the science is changing quickly around breast cancer. In small ways, but in sometimes significant ways, and so it’s really good to be up on the latest science and talk to as many oncologists early on as you can.

IRA FLATOW: Is the internet a good source of stuff, or are people going to be listening to stuff that has not been vetted and hearing stories that are going to misinform them?

KATE PICKERT: I would say, by and large, there’s a lot of inaccurate information on the internet. We all have that inclination to go to Dr. Google, but the reason that I really don’t advise patients just google around and look for things online is because, because the science is changing, a lot of the information online is outdated.

So for example, some types of breast cancer, including the type that I had, actually there are really good treatment options for that type of breast cancer now, but if you go online, there’s a lot of information that was put there before some of these new treatments were around. So information is outdated, and unless you’re adept at reading medical journal articles and things like that, I think it’s best to get your information from doctors directly.

IRA FLATOW: But you’re one person who is adept at reading these things. What must it have been like for you, a health care journalist, who is used to poring over medical studies and writing about patients? Then all of a sudden, you are one of those patients.

KATE PICKERT: Yeah, I mean, just like any other woman or man diagnosed with breast cancer, it was a very terrifying experience, especially in the beginning, before I understood much about the disease or the treatment that I would undergo.

I think that being a health care journalist and having had some experience writing about cancer and reading medical journal articles, I think was really empowering and helpful for me. Because when my oncologist would explain a particular drug to me and say it’s based on this study and this study, I think had the skills to go look those up and read those studies.

So I think it was empowering for me as a patient to have had that health care background. At the same time, I’m a human being in addition to a journalist. And it was very scary at the beginning, yeah.

IRA FLATOW: Did you know where to turn to, to seek advice, even with all of your experience?

KATE PICKERT: Well, the first thing that I did was look around for the best comprehensive cancer center in my area, which is Los Angeles. And so I made my way to UCLA. I reached out to everyone I knew who might have any connection to oncology, to try to find out who are the best oncologists at UCLA that I could see, or elsewhere in Los Angeles.

So I had a lot of consultations in the first month after my diagnosis. Almost every day, my husband and I would drive. We were criss crossing LA County, talking to different doctors, et cetera. So I think that I was really lucky to find some great oncologists fairly quickly, in part because I was in a big metropolitan area. Which is not the case for everyone.

IRA FLATOW: Yeah, and it’s interesting that you bring that up, because that was one of the most light bulb moments of your book, when I was reading it. I was surprised to learn that, while you’re out there in LA, the doctors in the East Coast are prescribing some other kind of medication. You describe it as an East Coast versus West Coast divide in how to treat cancer.

KATE PICKERT: Yeah, I mean, I spent 10 years living in New York City before I moved to Los Angeles, and I’m originally from Upstate New York. So I think I myself have a little bit of an East Coast bias. So right after my diagnosis, my first thought was, I need to get to New York.

But actually, it really turned out that UCLA was pretty much the best place in the world for me to be treated, because it’s ground zero for research into the type of breast cancer that I had. But you’re right, there are cultural differences between doctors on the East Coast and the West Coast.

And this isn’t true for every single doctor in New York or LA or San Francisco, but I write in the book about different chemotherapy regimens that are more commonly prescribed on the East Coast, compared to chemotherapy drugs delivered on the West Coast.

And this is a cultural difference, and doctors, oncologists that I spoke to in both places admitted this. The chemotherapy regimen that I write about in the book that’s more common on the East Coast is an older chemotherapy regimen. It’s very toxic, and it’s basically statistically significant to this other chemotherapy regimen that came along later.

And yet doctors on the East Coast still deliver this chemotherapy regimen, even though it’s more toxic than this other chemotherapy combination more commonly prescribed in California, for example.

And the reason I wrote about that was, it was interesting and something I didn’t know, that there were these geographic differences in treatment, but also to try to inform people, and women in particular, and breast cancer patients, that there may be differences, and you should ask about this and speak to your doctors a little bit about the science behind the decisions they’re making about what they prescribe.

IRA FLATOW: And you described the reason being that East Coasters and West Coasters in general, of course it’s not everybody, have a different mentality about how they want to be treated.

KATE PICKERT: Well, this is certainly what Larry Norton, who’s the breast cancer guru at Memorial Sloan Kettering told me. He said– he compared it to East Coast jazz and West Coast jazz. And he said– I don’t know the exact quote in the book, but he said basically, people in New York are more concerned about dying and less concerned with all of these important side effects, whereas people on the West Coast tend to go for treatment regimens that don’t cause a lot of side effects and are maybe gentler.

And I think as someone who’s lived on both coasts, I’m not sure that entirely describes the differences in patients, but definitely with doctors in New York, definitely think that they have the leading view on that.

And again, that’s not across the board, but that’s a lot of physicians in New York, yeah.

IRA FLATOW: Yeah, it’s like they talked about, we have the best bagels.

KATE PICKERT: Right. Well, that’s true, though.

[LAUGHTER]

IRA FLATOW: You’re write some really fascinating history, because I love history of science. You write in the book about the history of breast cancer, and it surprisingly goes back to a Scottish medical student in the 1800s, who was studying lactation in sheep.

KATE PICKERT: Yeah, I mean, I wanted to write about so much of this history in the book, just to convey to readers how much of science, especially in the early days, was because of chance, and it was random and very, very messy.

So yeah, there was this medical student named George Beatson, and in the late 1800s, I think in the mid-1870s, he was finishing up his medical studies, and he had one more thesis paper to write. And so he got a side job helping a wealthy man who lived out in the countryside in Scotland. It was a side gig for him.

So he thought, OK, I can live with this guy and earn a little bit of money, and I’ll work on my paper. And so some sheeps were being weaned at a farm nearby this estate, where Beatson was staying. And so he wrote his paper about lactation.

And so in the course of that research, he learned what a lot of farmers have known for a long time, which is that lactation, and milking animals and mammary function, is very closely tied to an animal’s ovaries.

So this idea that there was this connection between breasts and ovaries was something that Beatson was absolutely fascinated by. During lactation and during breast cancer, both, there are a lot of cellular changes in the mammary glands.

And so Beatson knew this and wondered, gosh, I wonder if ovaries are connected to breast cancer. And so he set this notion aside for some years, but later, when he was a doctor in Glasgow, he would see a lot of breast cancer patients in the hospital. And back then, there was really no treatment for breast cancer, other than some surgery.

Basically, a lot of women diagnosed with breast cancer died fairly quickly. And so Beatson thought, well, I’m going to try an experiment. And so the first woman that he proposed his idea to was a 33-year-old mother of two with a very bad case of breast cancer, and he asked the woman if she would allow him to surgically remove her ovaries in hopes of slowing down her breast cancer. And she agreed, and he did, and the operation was successful in that it did slow down and make her breast cancer regress.

And so that was an amazing discovery. On the one hand, it was discovered that there may be that surgical removal of ovaries could be a treatment for breast cancer, or something outside of mastectomy could treat breast cancer. And in addition, Beatson and other doctors in the early days that tried the surgery, they realized that not all women’s cancers responded.

So the other also very, very important discovery was that not all breast cancer was the same.

IRA FLATOW: That’s interesting.

KATE PICKERT: So some is fueled by hormones, some is not, and that’s driven research into the disease ever since.

IRA FLATOW: Terrific work. We’re going to talk more with Kate Pickert, author of Radical, the Science, Culture, and History of Breast Cancer. Stay with us. We’ll be right back after this break.

This is Science Friday. I’m Ira Flatow. We’re talking this hour about the cultural history of breast cancer and the science and how to diagnose and treat it, with my guest Kate Pickert, author of the book Radical, the Science, Culture, and History of Breast Cancer in America. We have an excerpt on our website at sciencefriday.com/radical.

Kate, you really have covered a whole bunch of territory in this book. It must have been really terrible to try to figure out what to leave out, because there is so much in there. Let me go to a common question people ask you when they find out that they have cancer. And they already want to know what stage they’re in, right?

KATE PICKERT: Mm-hm.

IRA FLATOW: This idea of the question of staging has changed over the years, has it not?

KATE PICKERT: It has, indeed. And I got this question so much after my diagnosis. And this question has become very complicated, actually, for a couple of reasons. One is that in the past, the way doctors would stage a breast cancer was by measuring how large a tumor was and how many lymph nodes were involved, that were also invaded by disease, in basic terms.

And you can only really truly figure that out by removing the tumor and then measuring it. So through surgery. And these days, a lot of women, including me, receive chemotherapy and other drug treatment prior to surgery. So that changes– if all goes well, that changes the disease and sometimes can shrink it dramatically, and so it’s difficult to ever know the true stage for some breast cancer patients.

But additionally, the other thing is, that we’ve learned so much about breast cancer since the original staging system was devised. And recently, there have been a lot of other factors added to the equation for staging.

So we now know that actually the biology of a breast cancer tumor, what type of breast cancer it is, is just as important, in some cases far more important, than the size of the actual tumor.

So there can be some types of breast cancer that are very aggressive, spread rapidly, and can be discovered when they’re very, very tiny and be very dangerous. And then there are other breast cancers that grow very slowly, that are highly treatable, that may be large when they’re discovered, and doctors still may be able to treat those effectively.

So yeah, this question of what stage is it, as if that is a complete picture of prognosis, is much more complicated and not as true as we used to think it was.

IRA FLATOW: And that’s interesting, because it leads to my next question about the kinds of cancer. You mentioned there are all these different kinds of cancers and how to detect them. Talk a bit about mammography, because you write in the book that we’ve gotten really good at finding the wrong cancers, things that may not be cancer or may never return or turn into cancer, but we still have trouble finding the right cancers, the kind that will kill and need to be caught early. Tell me more about that.

KATE PICKERT: Yeah, I mean, and this is really based on the idea, based on the fact that mammography, which is the primary means that we used to screen women for breast cancer, is a pretty crude technology. There have been some advancements with digital mammography, but it’s still an X-ray. And so an X-ray is not a particularly sensitive tool for soft tissue, which is what a breast is.

So it is the case that a lot of women breast cancer detected through screening mammography. And in a hefty number of cases, those breast cancers really needed to be found and were dangerous.

However, since the advent of widespread screening mammography, we’ve also begun to pick up a lot of very, very, very early breast cancer. One particular issue I write about in the book is this issue about DCIS, which is also known as stage zero breast cancer. And these are very, very early cellular abnormalities that are not invasive disease yet.

And so because we’re picking up so much of this, and DCIS causes microcalcifications, and so that’s why it can be picked up on mammography. And so we’re doing a lot of surgery on these patients, whose disease wouldn’t have been detected in the past.

So that’s one issue, but I actually argue in the book that I think the more important issue is that there are cancers that are not found through a screening mammogram. So this is particularly true for women with dense or very dense breasts. Oftentimes, young women who are premenopausal. And because their breasts are so dense, a lot of times that breast density can obscure an invasive breast cancer tumor that may be present, and therefore may not be able to be picked up by a mammogram. But we are very reliant on mammography. It’s our primary means. Almost across the board, this is what everyone gets. And this has been the case ever since widespread screening mammography began in this country in the early 1970s.

But what we’ve learned so much since then, and so there are efforts underway to try to personalize screening in the way that we have personalized treatment. Some women are at high risk for developing breast cancer, and some women are at very low risk, and we can actually stratify women by risk to some degree.

And then hopefully in the future, we will be better able to tailor screening, so use other modalities like ultrasound and MRI, screen more frequently or less frequently, depending on an individual situation.

So I think there is a paradigm shift underway, and I think that’s where the science is going.

IRA FLATOW: And when you say a paradigm shift, is it toward a different kind of screening, perhaps like MRI or toward what?

KATE PICKERT: I think when I say a paradigm shift, I’m talking about, instead of a one size fits all approach, actually interviewing an individual woman at age 40, or at age 50, to ask, OK, tell me about your family history. Maybe we’ll do a little bit of genetic testing. Tell me how old you were when you had your first period. If you’re postmenopausal, how old were you when you entered menopause?

These are things that can affect a woman’s risk of developing disease, and then tailor, then saying maybe to some woman who’s at very high risk with a lot of family history of breast cancer, you need to be screened every six months with MRI, which is very different than what most women who enter into the screening system now undergo.

IRA FLATOW: Mm-hm.

KATE PICKERT: Yeah.

IRA FLATOW: And we’ve had the discovery of the BRCA genes, things like that which have totally changed cancer screenings, has it not?

KATE PICKERT: Yeah, I mean, it’s changed it for people who are found to have the BRCA mutation. And there are lots of other mutations that we are now learning more about and becoming aware of. So it’s not just BRCA anymore. The genetic panels given to women can look for a lot of other types of mutations as well.

And in fact, I mean, in general, the only people screened for BRCA are usually people diagnosed with breast cancer, even though not all women diagnosed with breast cancer but young women in particular, or women who have a significant family history.

And there have been calls in recent years, including by the scientists who first discovered the BRCA gene at Berkeley decades ago, should we perhaps be screening all young women for genetic mutations that may affect risk?

And this is another area that there’s a lot of discussion about now. The same way that we screen all women for breast cancer, should we screen all women for genetic mutations to try to better understand their risk?

IRA FLATOW: And one commonly held belief is that earlier– the earlier you screen for breast cancer the better, because you’ll save more lives. But the science doesn’t really back that up, right? How did this belief in early mammography take hold?

KATE PICKERT: Yeah, I mean, this is one– I mean, I had written about this issue. I’d written a couple of stories about it before my diagnosis, back when I was a staff writer for Time Magazine. So I was a little bit familiar with this issue, but I went deep into the research for my book.

And what I found was, I mean, basically, the source of controversy that your listeners and most people may have heard about is this debate over when should women begin screening for breast cancer? Should they start getting mammograms at 40 or 50?

And there’s been a lot of consternation and arguing and debate and passion about that issue, especially over the last 10 or 15 years. But what I found in my research is that that debate over that age group, women age 40 to 50, and whether screening mammography helped them? That debate and that dispute has existed ever since the first breast cancer screening trial data was published in, I think, 1971.

So we’ve always known, at least scientists have always known, that mammography is flawed, and that it doesn’t work as well for– it works differently for different people, and yet we haven’t really done anything to change how we do screening. And I think this is rooted in the fact that breast cancer is very scary. The idea that there is a test that could find it early and save your life is a very alluring idea.

And I think also, we give women very simplistic messages, right, about breast cancer. Early detection saves lives. Get your annual mammogram. And that’s the only message a lot of women get about breast cancer and about early detection and breast cancer screening. And the picture is far more complicated.

IRA FLATOW: So what are your recommendations for women about screening and detection?

KATE PICKERT: One study that I write about in the book was this study that showed that 90% of women do not know their true risk for developing breast cancer. So there are actually online really– there’s one, I think, from the NCI and others from some really good nonprofit groups that have risk calculators online, so you can put in your data, your age, family history, and things like that, and it will help give you some idea of whether you’re at above or below average risk for breast cancer.

But what I tell women is that you should have this discussion with your physician. And a lot of times, that discussion never happens. Your gynecologist or your primary care physician says, oh, you turned 40? Go get a mammogram, and that’s the end of it.

So I think starting a discussion with your health care provider is really helpful. Knowing your risk is really helpful. And also there are some trials going on right now that are stratifying women by risk and paying a lot more attention to individual patients.

So I would urge people to look at those as well, and see if they could participate in science and maybe get better care along the way.

IRA FLATOW: Yeah. The last time I was at my personal doctor, we were talking about things, and he said, you should start examining yourself for breast cancer. And I said, men? He said, oh, yeah. He said, I’m telling all of my male patients. And you write that breast cancer does occur in men, and kills more men every year than testicular cancer.

KATE PICKERT: Yeah, that’s right. And actually, I mean, that’s wonderful that your doctor said that. I would wager that most men in America are not getting that advice, but it’s good advice.

And actually, I mean, it’s important to know that more than half of all breast cancers diagnosed in this country are diagnosed after a patient finds a lump themselves, not through screening mammography.

So we may have this belief that that’s how it’s always caught, but actually, it’s caught more often by touch.

IRA FLATOW: Mm-hm. you write that a lot of cancer treatments in the book take a psychological and physical toll, taking all the estrogen out of a woman’s body, for example. How well are we able to deal with these side effects?

KATE PICKERT: I think we’re getting better all the time. But still, oncologists are focused on saving your life. They’re less focused on making you more comfortable along the way. And I think good oncologists recognize that trying to convince a woman to stay on treatment has a lot to do with, can you manage my side effects, right?

So in a way, managing side effects can sometimes be lifesaving, because a patient may not want to undergo a treatment with severe side effects, and then may lose the benefit of that treatment. I mean, you mentioned women on endocrine therapy, which is basically a way to remove estrogen from the body. And this has a lot of downstream side effects, including it can cause joint pain, mental fog, sexual dysfunction, and lots of other–

I mean, we are built as women and men to have estrogen in our bodies. And so having none can have some of these other impacts that we’re not expecting nor want.

IRA FLATOW: That leads me to a quote from your book, where you say, “chemotherapy represented a huge leap forward in treatment for breast cancer patients. Now doctors know that taking a few steps back is also progress.” What did you mean by that.

KATE PICKERT: What I mean by that is, surgery, radiation, and chemotherapy, these are the three main treatments that have been prescribed to women for many decades and that we’re all pretty familiar with.

And now enough progress has been made in breast cancer that scientists and doctors are now looking at, like, do we need to do everything that we have been doing? As we develop targeted therapies that are a little bit better, and as we’re able to do you know large scale randomized trials and big studies and meta analyses, physicians and scientists are learning that a lot of women who have been prescribed surgery and chemotherapy in particular, perhaps did not benefit, or would have just as big a benefit from a smaller approach on that scale.

So I mean, there was a large study that came out a couple of years ago called The TAILORx study, which basically used a genomic panel, a test, to test women diagnosed with hormone positive breast cancer, where the test would return results saying whether that woman would benefit from chemotherapy or not.

And the results of the study basically showed that a lot of women, as many as 60,000 women a year, who had previously been getting chemotherapy, did not benefit from it. And so now, those types of women are not getting chemotherapy.

So as the science marches forward, we’re learning a bit about how to subtract some things from the menu from some patients, which I think is tremendous progress.

IRA FLATOW: Kate Pickert is with me. She’s the author of Radical, the Science, Culture, and History of Breast Cancer in America on Science Friday from WNYC Studios.

So there’s so much to talk about. I want to end on a really fascinating story, a fascinating story about a chance meeting in a Denver airport, you write, that was the catalyst for one of the most important breakthroughs in cancer, meaning Herceptin. Tell us about that.

KATE PICKERT: Yes, so Herceptin is one of the really huge– one of the only major game changers that we’ve seen. So we’ve seen a lot of incremental progress here and there, but Herceptin was a game changer. And Herceptin was invented, was developed by Genentech, the biotech company based in San Francisco, in collaboration with a scientist at UCLA.

And this scientist at UCLA and a scientist at Genentech had both been working on oncogenes separately. And they happened to be aware of one another’s research, and they did run into each other in leaving a conference at a Denver airport and start talking about whether they might work together.

And this scientist at UCLA was taking care of all of these cell lines, and trying to study whether there might be another subtype of breast cancer that could be treated with a targeted drug therapy.

So we know that endocrine therapy, anti-hormone, anti-estrogen therapy was effective, but there weren’t really any other specific drugs. And so the scientist at Genentech made a probe, basically, that allowed– that he sent to the scientist at UCLA, who was able to basically, through some really smart research, discover that there was one group of women diagnosed with breast cancer whose breast cancer had a very, very poor prognosis, and a very clear target on the cells that existed.

And finding that target was really the key, because then Genentech was then able to develop a drug that hit that specific target. And so it was a chance meeting. Genentech wasn’t initially very excited to develop this drug, and was pushed by the UCLA scientist to do it. And so they collaborated and developed Herceptin, one of the most important cancer drugs in cancer history.

IRA FLATOW: Mm-hm. So many stories. I really commend you for writing this book, because I think this will help so many people understand breast cancer and take action when they read the book.

KATE PICKERT: Thank you so much. Yeah, I really want women to feel like they– and men– to feel like they have some agency. And also, it’s just a fascinating story of history that teaches us a lot about science in general.

IRA FLATOW: Yeah, all kinds of interesting stuff, and even about how much luck played a hand in your life.

KATE PICKERT: Yes.

IRA FLATOW: Well, it’s in the book. If you want to read about it, get a copy of Radical, the Science, Culture, and History of Breast Cancer in America. Kate Pickert, former staff writer at Time, thank you. Thank you so much for taking the time to be with us today. We have an excerpt from her book up at sciencefriday.com/radical.

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