This interview has been conducted in partnership with the National Breast Cancer Foundation (NBCF). Recognized as one of the leading breast cancer organizations in the world, NBCF is Helping Women Now® by providing early detection, education, and support services to those affected by breast cancer. A recipient of Charity Navigator's highest 4-star rating for 14 years, NBCF provides support through their National Mammography Program, Patient Navigation, breast health education, and patient support programs. For more information, please visit https://www.nationalbreastcancer.org/

Oncology Data Advisor: Welcome to Oncology Data Advisor. In this interview, Lillie Shockney, Professor of Surgery at Johns Hopkins University, will be discussing the pathology of breast cancer. Thanks so much for joining us today.

Lillie Shockney, RN, BS, MAS, HON-ONN-CG: Thanks for having me.

Oncology Data Advisor: What is the pathologist trying to determine when looking under the microscope at breast tissue from a biopsy or from breast cancer surgery?

Lillie Shockney: First they're looking to confirm that this is breast cancer and what kind of breast cancer it is. The most common form is invasive ductal carcinoma; 80% of women are diagnosed with that type. There's also a slightly rarer type called invasive lobular carcinoma, which actually grows differently. We need to do breast magnetic resonance imaging (MRI) in order to actually see its true size. It usually doesn't show up very well on mammograms. They're also looking to see how rapidly these cells are multiplying and subdividing, known as the grade. Grade 1 is slow-growing, grade 2 is moderate-growing, and grade 3 is fast-growing. Most breast cancers are grade 3, but "fast-growing" is a relative term. To be a 1 cm tumor, you need 2.5 cm to equal 1 inch, so you're looking at something about a third of an inch in size. With it being a grade 3, it's been growing for about five years, yet it's a grade three, so it's considered rapidly growing.

The pathologist also does some special tests on those breast cancer cells to see what reactions there are for specific receptors, including the estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 (HER2). Estrogen and progesterone are the two female hormones that are in women's bodies, but men also have estrogen in their body, just not as much as we have. We also have some testosterone and some androgen in our body, just not as much as men do. Even if it's a man's breast cancer, it's tested for estrogen and progesterone to see whether or not estrogen and/or progesterone, particularly estrogen, stimulate these breast cancer cells to grow. If it does, then it is deemed to be estrogen receptor–positive. The pathologist is actually determining the degree of positivity. Rather than just saying it's positive or it's negative, they determine if it's 80%, 90%, 100% positive.

That is something that is relieving to say, believe it or not. We want it to be hormone receptor–positive because we have drugs called hormonal therapies and CDK4/6 inhibitors that we can give a patient to block the ability of estrogen, which is naturally in her body, to reach a breast cancer cell and feed it anymore. It starves those breast cancer cells because the fuel to feed them was, in fact, her female hormones. That's a good thing. Now HER2 is a protein that the breast cancer cells have within it. If that breast cancer cell overproduces that specific HER2 protein, then it is HER2-positive. It is considered to be a mischievous cancer, an aggressive cancer, and a little harder to treat, as well as one that might want to return.

Now it used to be that if it was HER2-positive, we would say, "I'm so sorry your tumor is HER2-positive." Today, we're able to say that we now have drugs specifically for HER2-positive disease. She will be given one or several of those drugs and usually receives them for a year. They're given by intravenous infusion. They were so incredibly effective when the research studies were done using the very first drug in this family, the trials ended very early because they could see that it was shrinking their tumors. It was shrinking it in their liver, in their lungs, in their bones; it was incredible. They said, "Stop the trial. This drug works. Let's give it now to everyone that participated in the trial, including those that were getting a placebo with chemotherapy." That was very exciting. I was in clinic seeing patients when that news came through, and boy oh boy, we were dancing in the hallways over that. That was absolutely fabulous.

There are some other more subtle prognostic factors that the pathologist will also look upon. For example, Ki-67 is a different way to measure the aggressiveness and the rapidness of these tumor cells growing. There's also something called luminal A and luminal B that today we are not necessarily using to help determine specific treatments, but I do believe that we will in the future. Everyone thinks that we should have a cure by now for breast cancer. Believe me, the world underestimates just how complex this disease is. There are no two breast cancers that are the same. There are many, many, many, tiny little minuscule features of these cells that are in and of themselves unique to that patient and only to her. It's going to take us quite a few more years before we decipher all of this and then can figure out, biologically, how to control it.

Immunotherapy is what we're now using, which is a different way of treatment. It's a very different way of treatment, using our own immune system to stop cancer cells in general, because we have been using it for lung cancer and melanoma for quite some time. I'm excited to see us in the land of immunotherapy, but there will even be other treatments that will come out to be able to squash this disease as soon as it's identified or even give us a vaccine to prevent it. I believe my granddaughter, who is almost 13, is part of the generation that will see a breast cancer vaccine. I know she will.

Oncology Data Advisor: How important is it to have a breast pathologist rather than a general pathologist do this type of evaluation?

Lillie Shockney: Any time you're dealing with cancer, this is when you need the highest level of accuracy. Research studies have been done to prove that a breast pathologist is more accurate in reading results under that microscope than a general pathologist, who's looking at pancreatic cancer, lung cancer, brain cancer, prostate cancer. They're all different; they all have their own idiosyncrasies. You want a breast pathologist because breast cancer is all they see all day, and they're going to be more accurate. You also want to make sure that where your pathology slides are prepared and reviewed has two breast pathologists: one reading these pathology slides and coming up with the answers, setting those slides over here to the left, and a second breast pathologist picking them up and putting them under the microscope and reading them all over again without any discussion between the two doctors. Their pathology reports must match or no results are to be given, because people make mistakes. People make mistakes.

There are a lot of facilities that only have a pathologist to read everything that comes through the door. There's no one to do quality control on him or her and there's no one to train them how to specialize in any particular kind of cancer. The pathologist ironically holds all the cards. The treatment decisions recommended to the patient are based on what the pathologist found, and yet the patient may never meet that person. Yet when you think about it, the pathologist is the most important person because they determine that a patient has cancer, what kind of cancer it is, what prognostic factors it has, and how fast it is growing, which then sets the treatment options.

Thank you for listening to Oncology Data Advisor. Be sure to check back throughout Breast Cancer Awareness Month for more of this exclusive interview series, all found at oncdata.com.

About Lillie Shockney

Lillie Shockney, RN, BS, MAS, HON-ONN-CG: her name is well known in the cancer field, especially in navigation, survivorship, patient-centered care, preservation of quality of life, end-of-life planning and care, and improving the cancer patient's experience and clinical outcomes. She clinically specializes in breast cancer care. Her public speaking, literary work, and notable roles over the last 40+ years are well known to many:

•University Distinguished Service Professor of Breast Cancer (2016-present)

•Former Administrative Director, Johns Hopkins Breast Center (1997-2018)

•Former Director, Johns Hopkins Cancer Survivorship Programs (2011-2018)

•Professor of Surgery, Johns Hopkins University School of Medicine (2016-present)

•Co-developer and medical advisory of Work Stride: Johns Hopkins Managing Cancer at Work

Program (2012-present)

•Co-founder, Academy of Oncology Nurse Navigators (AONN+) (2009-present)

•Former Program Director of AONN+ (2009-2019)

•Editor-in-chief of the Journal of Oncology Navigation and Survivorship (2012-present)

•Author of 20 books and >350 articles on various cancer topics

•National and international public speaker (1997-present)

A two-time breast cancer survivor, originally diagnosed in her 30s, Lillie has worked tirelessly to improve the care of breast cancer patients around the world. She has worked at Johns Hopkins since 1983. Lillie takes great pride in the AONN+, which as of April 2020, has more than 8,900 members. She has served as a consultant for breast cancer for national ABC News and Good Morning America and has been also consulted regularly by the Today Show and CNN. Lillie serves on 28 medical advisory boards currently. In 2008, the President of The Johns Hopkins University and their Board of Trustees appointed her to a Distinguished Service Faculty Chair. This is the first and only time in the history of the institution that a hospital nurse has been appointed to a distinguished service designation. She continued to climb the academic ladder and in 2016 was promoted to full professor. She is the only nurse at Johns Hopkins to have a primary faculty appointment in the School of Medicine and the only nurse in the country to have reached the highest academic faculty ranking and be appointed to a faculty chair as a University Distinguished Service Professor of Breast Cancer at Johns Hopkins University School of Medicine.

She has received 61 awards—54 national awards and 7 state awards, including being inducted into the Maryland Women Hall of Fame, Women in Business Healthcare Trailblazer Award, Johnson & Johnson's Most Amazing Nurse in America award, National Komen for the Cure's Professor of Survivorship award, and several national lifetime achievement awards. Her research area of focus is preservation of quality of life for patients with metastatic breast cancer. Currently, a documentary is being made about her life and her life's work. She tells people she never forgets where she came from—she will always be "a farmer's daughter."

Transcript edited for clarity. Any views expressed above are the speaker's own and do not necessarily reflect those of Oncology Data Advisor.