Breast Cancer Care in the Era of Covid-19

It’s been a while! I’ve taken time to recover from my mastectomy (will blog about that later) and, like many folks in self-isolation, I’ve been doing things like gardening, cooking/baking, home improvement, and family activities to fill the time. I waver between being grateful, bored, peaceful, restless, and generally anxious about the immediate and long-term future.

Photo Credit Deposit Photos

And, like many other people battling cancer in the midst of the pandemic, I’ve been dealing with uncertainty about my ongoing treatments on top of the “normal” concerns. I’ll get to my specific case in a bit, but first we’ll go over highlights from a recently published article.

How has cancer care changed in the era of Covid? A recent article from the New England Journal of Medicine provides insight into some of the challenges for breast cancer care. The article is part case study and part discussion of alternative approaches to cancer care designed to mitigate risks of cancer patient exposure to SARS-CoV-2 in healthcare settings. These include delays in surgical tumor removal in some cases where rapid growth/progression of the tumor isn’t a significant risk. One interesting approach is the use of neoadjuvant (a fancy term for treatment before surgery) endocrine therapy (a fancy term for use of estrogen hormone blocking agents like tamoxifen and aromatase inhibitors). As discussed in the article, the advantages of this approach for hormone receptor positive breast cancer include: 1) shrinking the tumor before surgery and improving chances of getting clear margins (no extra tumor left behind after surgery); 2) making breast conserving surgery a safer and more aesthetically pleasing option; 3) giving more time for genomic testing (e.g. OncoType DX – will blog about this later, too) results to come back; 4) determining sensitivity of the patient’s tumor to estrogen suppression, which can also help with the decision whether or not to add chemotherapy.

Photo credit Deposit Photos

The downside, of course, is that delayed surgery and neoadjuvant endocrine therapy require more monitoring (examination, imaging, biopsy, etc.), which takes place in healthcare settings and increases the risk of exposure to the virus. With chemotherapy, which targets rapidly dividing cancer cells (along with hair follicles, cells lining the gut, and immune cells), the risks for exposure to coronavirus is especially problematic as patients are rendered immunocompromised (unable to fight off infections with the body’s natural defenses) or immune fragile (less able to fight off infections). Approaches to mitigate these risks are discussed in the article for hormone receptor positive breast cancer as well as HER2+ and triple negative subtypes. It also discusses ways healthcare providers can and should effectively communicate with patients about treatment decisions and risk management.

Communication – this is an ongoing issue with my care. There are many factors, not the least of which is Covid-19, but we’ve had some…confusion about the schedule for reconstruction following my mastectomy (Note: the surgical team managing my case are PHENOMENAL at what they do, but in both cases, communication with me has not been on par with their skills). When we first scheduled the mastectomy, we also discussed which option might be best for reconstruction and settled on a TUG flap autologous reconstruction. This will involve using a flap of skin, fat, muscle (transverse upper gracilis), and blood vessels from the upper thigh is used to reconstruct the breast. It is a rather involved surgery, which includes microsurgery to reattaches the blood vessels of the TUG flap to the blood vessels in the chest. The nature of the grafting procedure means close monitoring to make certain the graft has sufficient blood flow to survive and thrive, and therefore requires a one night stay in the ICU.

An ICU stay in the era of Covid-19 is a risky and scary prospect!

Because of the risks, my plastic surgeon called and suggested we postpone reconstruction (could have theoretically been done immediately after mastectomy) to minimize the risks of exposure to the coronavirus. That made perfect sense and I agreed. During this conversation, he mentioned reconstruction 6-8 weeks following mastectomy (scheduled for May 11 – meaning reconstruction around June 22 – July 6).

This did not happen. I *think* what happened was a change in timeline due to the need for an expander implant after surgery – this serves as a temporary, fillable implant that can stretch the skin in preparation for reconstruction. I had a skin/nipple sparing mastectomy (glad the nip made it – it was dicey for a week or so), and the expander sat underneath the skin. With an expander, weekly injections into the port with saline gradually increases tension on the skin and stretches it. When I first started expansion, there was talk from the doctor about reconstruction in August.

This did not happen. I *think* it’s because the doctor forgot to let me know that there’s a three month waiting period between the last expansion and reconstruction. Right now, as far as we know, I’m looking at reconstruction around the end of September/beginning of October.

I hope this happens. Again, healthcare providers and patients must be flexible during the pandemic. I trust that my team will make the safest decision about reconstruction.

I just kind of hope they keep me in the loop!

Covid-19 and Cancer – Self-Isolation Isn’t Just About You

On this, my second “Cancerversary,” I want to urge my fellow citizens to take this pandemic seriously, shelter-in-place, flatten the curve, and listen to scientists and health experts rather than politicians and rabble-rousers who value the economy over health and safety.

I originally submitted this as an Op-Ed to several news outlets, but in light of my upcoming surgery, the first of two thanks to Covid-19 dangers that have delayed my reconstruction following mastectomy, I decided to do a blog post. This is important. We’re all in this together, and those who choose to ignore expert advice are putting people like me in danger.

This isn’t the time to be selfish. Self-isolation isn’t just about you.

Like many Americans, I’ve been working remotely to comply with social-distancing and shelter-at-home measures. As a biomedical research scientist, I understand the particularly insidious way SARS-Cov-2, the coronavirus behind the deadly pandemic, can be transmitted exponentially through populations. Death tolls are rising. We’ve been told we need to flatten the curve, which means we need to slow the spread of the virus so we do not exceed the capacity of the healthcare system to treat severely affected patients. There are a limited number of ventilators available, a message that was driven home by Dr. Emily Porter, board-certified emergency physician and sister of U.S. Representative Katie Porter. Dr. Porter used her sister’s approach to educate the public on how exponential spread of the virus could overwhelm the U.S. Healthcare system, forcing doctors to ration resources and decide who gets a vent and who doesn’t. It’s a horrifying, ugly scenario with 1 patient in 50 getting a vent, and 49 patients left to die.

What will happen if we don’t flatten the curve and instead overwhelm the healthcare system.

Her words at sent chills down my spine. “Imagine if you had to say, ‘Oh, I’m sorry. You’ve had cancer before, so therefore you don’t have a perfectly clean bill of health, so you’re not worth saving.’” I am a person living with cancer. My surgery has already been postponed due to the pandemic. Luckily, my tumor is slow-growing, giving me the luxury of time. Many thousands of other Americans and cancer patients around the world do not have that luxury. Cancer treatments cannot be suspended during the pandemic. As I passed through the Vanderbilt-Ingram Cancer Center on my last day of work, I saw a room full of men, women, and children, some in masks, waiting for their chemotherapy treatments. On the floor below, others waited for radiation therapy, and in the hospital a block away, cancer patients were recovering from surgery. These people are not only at risk for exposure while at their appointments, they are also immune-compromised or immune-fragile due to their cancer treatments and are less capable of fighting off the virus. To put that in perspective, a portion of the roughly 650,000 cancer patients who receive chemotherapy annually, not counting those receiving radiation therapy or the host of other patients with co-morbidities, are already more vulnerable to covid-19 death. Without ventilators, an unfathomable number of these patients will likely die. If we ration ventilators based on co-morbidities like cancer, I wouldn’t get a vent if I became infected.

I don’t want to die. None of these cancer patients, or patients with co-morbidities like autoimmune diseases, obesity, diabetes, or others want to die. Can you imagine beating cancer only to succumb to a virus, knowing that your fellow humans didn’t care enough to follow measures to flatten the curve and that’s why you can’t get lifesaving ventilation? Imagine your mother, your grandmother, your child, a newborn baby, your best friend, your colleagues, and imagine life without them—knowing they are gone because the people in their communities didn’t care enough to follow the rules.

Until recently, Tennessee has had a subpar response to the pandemic. Nashville has fared better thanks to measures implemented by the mayor, but there are too many state and local communities that aren’t taking this seriously. I implore them and I implore each of you reading this: follow the rules. Social-distance, shelter-at-home, don’t go out unless absolutely necessary, and take precautions when you do. Wash your hands. Hunker down. We can and will get through this, but only if we all do our part. Please do your part so people like me don’t have to die.

Resources for Cancer Patients During Pandemic: American Cancer Society, Immuno-Oncology News, Breast Cancer News

Covid-19 and Cancer: What You Need To Know

Day three of quarantine for me. My institution is doing the right thing by sending us home. Shutting down laboratory research sucks, but by being cautious and practicing social distancing, we will survive, stay healthy, and be able to get back to work after this necessary pause. I’m privileged to have an employer that recognizes the necessity of these measures, and thanks to National Institutes of Health measures, I’ll still be paid. So my plan is to catch up on scientific literature review, write a review paper, and work with my student remotely on her manuscript in preparation.

I also plan to blog, to write, to spread a bit of information, humor, and hope through the Internet to folks near and far, starting with this post. I’ll cover a bit about the science behind the covid-19 virus – the type of virus, its origin, its mode of spread, and its capacity for mutation and formation of unique strains. Then, I’ll provide information and links to resources to help minimize the risk to cancer patients actively recovering from surgery, on chemotherapy and radiation therapy, and the general considerations patients and survivors should consider during this pandemic.

First, some nomenclature (fancy term for naming things): The virus is actually called Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), formerly known as the 2019 novel Coronavirus (2019nCoV). The virus causes the Coronavirus Disease 2019 (COVID-19). Covid-19 is used interchangeably by the media and government agencies for both the virus and the disease it causes. It’s related to the SARS-CoV virus that caused severe acute respiratory syndrome in 2002-2003, as well as MERS-Cov (Middle East Respiratory Syndrome). They are a part of the Betacoronavirus genus, which are characterized by a viral envelop and positive-strand RNA. What does that mean?

Transmission electron micrograph of 2019nCoV virus.
Link to source.

Structure: As you can see from the transmission electron micrograph on the left, the virus is round, and its internal contents are surrounded by an envelop. the spiky protrusions sticking out from that envelop are actually proteins. This inspired the name of this type of virus, as these proteins make the virus look like a crown. These proteins include: (1) clusters of the Spike, or S proteins, latch onto a specific protein on the target cell (receptor molecule), and also help the virus fuse to the target cell membrane and become internalized by the target cell; (2) the Membrane (M) glycoproteins are under the spikes, where they help maintain the shape of viral particles and bind to the inner layers of the virus; (3) Lipid (fat) is taken from host cell membranes during previous infections and incorporated into the viral particle; (4) Envelope (E) glycoproteins help assemble new viral particles and help with release and infectious properties of newly-formed viruses; (5) Nucleocapsid (N) proteins that bind and package the RNA genome also help the virus hide from the host immune system. See figures below.

From CDC.

Link to Source.

Viral Replication and Infection: These viruses break the rules of the Central Dogma of Molecular Biology (i.e. genetic information flows from DNA to RNA to protein – see previous post). Their genetic information is stored as RNA, which is normally the intermediate cells use to create proteins from the genes encoded by DNA. This works to their advantage, since they trick the infected host cell into translating viral RNA encoding the structural proteins that protect the virus, as well as protein processing. They also trick the host cell into replicating the viral RNA genome and packaging it into new viral particles that are then released from the cell to infect other host cells, as shown in the figure below. The cell surface receptor for SARS-CoV-2 is angiotensin-converting enzyme 2 (ACE2), which is expressed on, among other cell types, lung epithelial cells.

Link to source.

One of the most insidious things viruses do is adapt rapidly through mutation of their RNA genomes. This property is actually what allowed both the original SARS-CoV coronavirus and SARS-CoV-2 to cross species and become infectious to humans (zoonotic). SARS-CoV-2 may have originated in bats, and likely made the jump to humans in a wet animal market in Wuhan, China where domestic and wild animals were slaughtered for meat on site, allowing blood and meat from multiple species to mingle (some of the first patients were epidemiologically linked to the market in Wuhan – Reference Khan et al. J. Clin. Microbiol. doi:10.1128/JCM.00187-20 – hit me up for PDF since the article is not yet publicly available). Many infected individuals can be asymptomatic (not sick) while spreading the virus, which makes it even scarier (Lai et al., 2020, Journal of Microbiology, Immunology, and Infection, in press – hit me up for the PDF since the article is not yet publicly available).

Symptoms: Quoted from Khan et al. J. Clin. Microbiol. doi:10.1128/JCM.00187-10 “Clinical features associated with patients infected with SARS-CoV, MERS-CoV and SARS-CoV-2 range from mild respiratory illness to severe acute respiratory disease (1, 17). Both MERS and SARS patients in later stages develop respiratory distress and renal failure (1, 17). Pneumonia appears to be the most frequent manifestation of SARS-CoV-2 infection, characterized primarily by fever, cough, dyspnea, and bilateral infiltrates on chest imaging (17). The period from infection to appearance of symptoms varies. Generally, it is thought to be 14 days, however, a research group at Guangzhou Medical University reported the incubation period to be 24 days. In a family cluster of infections, the onset of fever and respiratory symptoms occurred approximately three to six days after presumptive exposure (41).” Testing for SARS-CoV-2 is performed by using reverse transcriptase polymerase chain reaction (RT-PCR) to amplify viral RNA in samples from patient until levels are high enough to detect.

Treatments: The bad news is that there are no effective treatments for SARS-CoV-2 infected individuals, though pre-clinical testing for remdesivir and chloroquine shows promise, and existing anti-viral targeting approaches may warrant testing. Vaccines are being developed, but will likely not be validated and available for several months to over a year. The best strategies include social isolation to prevent spread, and management of symptoms for infected individuals (but perhaps avoid ibuprofen to be safe). Reinfection is also possible.

What does this mean for cancer patients and survivors? People with cancer and people who are in active cancer treatment may be at higher risk for SARS-CoV-2 infection and severity of Covid-19 Respiratory Sydrome. Survivors not currently in treatment should not be at higher risk, but check with your healthcare team about the effects of ongoing systemic therapies and increased risk. The American Society of Clinical Oncology (ASCO) is sharing and updating information for cancer patients on their blog, and their recommendations as of March 18, 2020, include:

  • Be sure to have enough essential medications, both prescription and over-the-counter, to last for up to a month.
  • Create an emergency contact list that includes family, friends, neighbors, and community or neighborhood resources who may be able to provide information or assistance to you if you need it.
  • Finally, if you are scheduled for cancer treatments during the COVID-19 outbreak, have a discussion with your oncologist about the benefits and risks of continuing or delaying treatment.

These are additional measures, and cancer patients should definitely follow the social-distancing, frequent hand-washing, avoidance of touching face (eyes, nose, mouth) with hands, and avoidance of close contact with sick people. They do not recommend face masks as a way to prevent COVID-19. But if you’re sick with a respiratory illness, like flu or COVID-19, wearing a face mask could prevent the illness from spreading to those around you.

Bottom line: Stay in touch with your healthcare team for guidance on how to minimize exposure risk during ongoing cancer treatments, and follow general population guidelines for social-distancing, hand washing, and disinfection. Wishing you all continued health and safety!

Metastasis 101: How Breast Cancers Spread

Metastasis – the spread of cancer from its initial tissue of origin to another part (or parts) of the patient’s body – is deadly. Metastatic disease is, by and large, what kills people with cancer. It is an ongoing challenge for healthcare providers and researchers, and, as you may have guessed, it’s complicated.

But what exactly is metastasis? How does the process work? And why is it so hard to treat? I’ll cover what we know in this blog post, current and emerging therapies, and ongoing research designed to treat metastatic disease and allow cancer patients to survive and thrive by keeping their metastatic tumors at bay.

Here are the basics: tumor cells that have the ability to break away from the primary mass and invade the surrounding tissue can travel through the body via circulation (by entering the bloodstream directly or or by entering lymph nodes and from there, lymph vessels that shunt fluid back into circulation), invade a secondary organ, and begin to grow and form a new mass at the second location.

This isn’t easy for cancer cells to do. One of my grad school professors once referred to metastatic cancer cells as the decatheletes of cancer cells. Losing cell-cell contact with the tumor mass, invading the surrounding tissue, which is often a hostile environment without resources available to the primary tumor mass, is risky. Entering circulation is even more risky. The cells of origin for cancer cells are not normally equipped to withstand shear forces produced by flowing blood. They also have to avoid detection and destruction by immune cells, not only in circulation, but within the tissue of origin and within lymph nodes. Immune cells are programmed to seek out and destroy unhealthy cells, which may harbor bacterial or viral pathogens that threaten the body as a whole. Metastatic cells also have to crawl along blood vessel walls or hitch a ride on platelets, surviving in circulation without the resources available within the primary tumor mass.

From Schroeder et al. 2011 Nat Rev Can 12: 39-50.

If the metastatic cells manage to survive breaking away from the primary mass, evade vigilant immune cells, and travel through the harsh environment of the circulatory system, they face the arguably greater challenge of exiting circulation and setting up shop in an entirely different organ system that may or may not be similar to their original home. Think of them as colonists. They need to secure a space to live, gather resources from an unfamiliar landscape by competing with native cells that are better equipped because they belong, and they need to adapt and change the behavioral programs controlled by their genetic instructions in order to grow and establish a new tumor.

For breast cancer cells, common sites of metastasis include liver, lung, bone, and brain. Why those sites? One theory, the “seed and soil” hypothesis, argues that tumor cells are like plant seeds, which travel in all directions but can only live and grow if they land in compatible soil, meaning something about these particular organ environments allows tumor cells to take root. It’s an old theory, first posed by English surgeon Stephen Paget after studying autopsy records of 735 patients who died of breast cancer and spotting patterns.

During the process of invasion and metastatic spread, cancer cells experience a lot of pressures, and combined with a relatively unstable genome (covered in previous post), these pressures select for survival of cells that adapt in a process comparable to evolution by natural selection: cells that survive long enough to divide are more likely to pass favorable traits to their daughter cells. One effect of this process is that tumors formed by metastatic cells are often very different from the primary tumor, making them resistant to the therapies used to treat the primary tumor as well as other treatments. Often, they cannot be removed easily by surgery, are resistant to or quickly become resistant to chemotherapy, radiation, and targeted therapies, and grow at a rate that depletes the patient’s body of life-giving resources and causing the organs in which they are lodged to fail. In a nutshell, metastatic disease is incredibly difficult to treat.

So what can we do about it? The good news is that it is possible to manage metastatic disease in some cases, allowing patients to live longer with better quality of life. More therapies are extending the lives of patients living with metastatic breast cancer, including CDK inhibitors like Palbociclib [Ibrance; other similar drugs include Abemaciclib (Verzenio), palbociclib (Ibrance) and ribociclib (Kisqali)] that target cyclin dependent kinases that drive rapid proliferation of cancer cells, slowing their growth. Others include HER2 antibody-chemotherapy drug conjugates (delivers chemotherapy more specifically to HER2+ metastatic breast cancer cells), second-line HER2 targeted therapies, PI3-kinase inhibitors (which target a signaling pathway that is aberrantly activated in ~60% of cancers), PARP inhibitors (block DNA damage repair pathways to make cancer cells respond better to DNA damage inducing chemotherapy), and immune checkpoint inhibitors (activates T-cells in tumors and allows them to kill metastatic tumor cells) among others. See previous post for information about some of these molecular targets. For more on tumor immunology, click here.

These therapies extend the lives of metastatic breast cancer patients, but they are still a temporary fix. As mentioned above, metastatic tumor cells are tough, incredibly adaptable, and able to develop resistance to therapy. Another approach involves finding a way to induce or maintain tumor dormancy, a state in which tumor cells survive but remain quiescent rather than growing rapidly. Many metastatic lesions can persist in a state of dormancy for decades, and we do not yet understand what keeps them dormant, and perhaps more importantly, what activates their growth. But as researchers unravel the molecular mechanism that regulate dormancy and reactivation, new therapies can be developed to maintain dormancy – thus allowing cancer patients to survive and thrive during a normal lifespan in spite of their tumor burden.

Take home message: metastasis is a complex process that enables invading tumor cells to break away from the primary tumor, travel through the patient’s body, and set up shop in different organs. They are difficult to treat and are the main cause of cancer deaths, but current and emerging therapies to manage metastatic cancer are allowing patients to live longer, better quality lives.

For more information:, Susan G. Komen for the Cure, and the American Cancer Society

Nice Going, AACR (Salt on the Wound)

I didn’t plan on writing two blog posts in one day, but here we are. Because of my second diagnosis with breast cancer, I have to adjust my life and schedule to accommodate surgery, reconstruction, and other treatments. I had planned to attend the annual American Association for Cancer Research Annual Meeting in April so I could present my research on molecular regulation of breast cancer bone metastasis, network with colleagues, patients, survivors, and policy makers, and learn about the latest advances in the field.

Cancer has robbed me of that opportunity.

Since I’d already registered, I contacted AACR to let them know what was going on and to cancel my registration. Here’s what I wrote:

Short, sweet, to the point. I didn’t expect a reply until next week, but, to my surprise (and based on the tone of the reply, horror), I received a reply within a few hours:

So, after writing the American Association for CANCER Research to let them know that I cannot attend the meeting because I have CANCER, that’s the stone cold, insensitive, shitty reply I received. I could’ve let it slide, but, as I note in my response, I’m soooooooo done with bullshit at this point.

Here’s my reply (copied and pasted since it’s too long for a screenshot):

Dear David,

Wow. Just wow.

Two years ago, I would have just let this slide, been “nice” and “quiet” without causing trouble, like all women are taught to do. But two years ago, I was diagnosed with breast cancer. And, as of last week, my breast cancer is back. As such, I have neither the time nor the energy for bovine fecal material. That the current bovine fecal material is coming from the American Association for Cancer Research, an organization I’ve supported since my days as a graduate student (member 1998-present), just after a second diagnosis with breast cancer, makes it all the more horrible.

As I noted in my request, I have cancer. I will likely be undergoing surgery for the third time during the annual conference, which means cancer has cheated me of the opportunity to present my own research findings on breast cancer metastasis to my peers. Cancer will also steal time from my research, my family, my friends, and my life. 
So, in response to, “Please let us know if you still wish to cancel your registration,” um, yeah. Did you think I’d suddenly change my mind, or that my cancer would suddenly be all better so I can totally go to the meeting – my bad? What kind of stupid, insensitive question is that? Seriously, I have people who despise me who wouldn’t be that stone cold. Do you need proof of my diagnosis? I have CDs full of scans from my six biopsies and two lumpectomies. Do I need a doctor’s note? You can check out my blog where I’ve been documenting my story in an effort to let patients going through the same struggles that (a) they’re not alone, (b) knowledge is power so here are accessible data you can use to make informed healthcare decisions, and (c) to be a liaison between research and patients/survivors so the public understands how important our work is and so they’ll engage to help us better meet their needs.

You’d best believe I’ll be blogging about the AACR responding to the news that I have cancer and cannot attend the annual meeting with it’ll cost you $125. No “I’m so sorry for what you’re going through.” No, “What can the AACR do to support you during this difficult time.” Just, “We can understand your concern.”

You can understand my concern, you say. With all due respect, no, unless you’ve had cancer, you absolutely, positively cannot understand even a fraction of my concerns. Unless you’ve been hit by the sledgehammer of shock upon hearing those three horrible words, you have cancer, unless you’ve had to tell your spouse, your children, and your mother that you’ve been diagnosed with a deadly disease, unless you’ve endured the pain of surgery and recovery, the burns and fatigue induced by radiation, the indignity of estrogen suppression therapies that forever change you and your relationship to your body, unless you’ve endured sleepless nights wondering if you’ll live for another 5 years, 10 years, 15 years, and if/when cancer might come back and kill you, you have NO IDEA about my concerns. That’s completely insensitive, condescending, and wrong on so many levels.

But please, by all means, take the $125. You certainly need it more than I do. I don’t need to think about insurance deductibles, medication, bills to support myself and my family. 

And one last thing – you don’t get to call me “Dana” in a response like the one you offered. It’s Dr. Brantley-Sieders to you.

A little consideration, human decency, and kindness can go a long way. Coldness, disregard, and insensitivity can, too. Badly done, AACR. Badly done.

Photo credit

DIY Therapy for A Geek

I’ve come to terms with the fact that I’m not done with breast cancer yet. But I don’t have to like it, and I don’t have to pretend that I’m entirely okay. I need help. Still in therapy, meeting with my care team on Thursday to come up with a game plan to get rid of this stupid little 6 mm bastard of a tumor, and then meeting with the plastic surgeon the following Monday to discuss Tits 3.0.

It’s a lot. What’s keeping me sane right now, aside from my family, Netflix Comedy Specials, and cat videos on Facebook, is my work. Y’all, I get to kill breast cancer cells ALL THE TIME in the lab. It’s so cathartic and gratifying. I wish with all my heart it was as easy to kill cancer cells in patients as it is in little plastic dishes. It’s not, but what we discover in little plastic dishes could eventually lead to the next cancer therapy.

The message is clear – DIE BITCH ASS CANCER CELLS!

My amazing student, who’s working with cancer cells that are similar to mine (hormone receptor positive), saved a plate for me. Not only did she save a plate, she decorated it with an adorkable “destroy me” tag that made me giggle snort.

I adore her.

Naturally, we decided to video me killing cancer cells.

Videography credit Kalin Wilson

As noted in the video, please for the love of your health, do NOT drink hydrogen peroxide to kill you tumor. It’s #toxic and not in a way that will target your cancer. But, as you can (hopefully) see, it stresses out the cells in the dish, overwhelming their defenses against oxidative stress to the point of death.

But, having the power to kill tumor cells that are similar to those growing in my body helped me on a psychological level. And if any patients or survivors want me to kill cancer cells like yours in the lab, I’m down! Hit me up. I can use chemo drugs, approved and experimental cancer drugs, peroxide, detergents, soda (it totally works), you name it. Let’s get creative!

Advocacy 101 – What I Learned from Training

I learned so many new things today at Patient Advocacy Orientation! My best days are when I’m learning new things. It’s one of the things I love best about being a scientist, and it’s a great foundation upon which to build for my new work as a Patient Advocate.

What exactly are advocates and what do they do? In terms of Research Advocacy Programs, advocates are disease survivors (cancer survivors in my case), caregivers, and members of the community who provide the patient perspective to researchers to help shape the nature and direction of cancer research and patient care. Their role is critical, as they serve as a voice for patients, helping investigators tailor their research with patients concerns in mind – not just in terms of outcomes and sound science, but also in terms patient comfort, respect for patient rights and dignity, and beneficence. This means making sure the goals of research are focused on and aligned with serving patient needs and improving outcomes and quality of life.

This seems pretty intuitive, and I believe most investigators are truly committed and passionate about doing research that will make a difference, be it developing new treatments, better diagnostic tools, reducing side effects of existing treatments, and improving survival and quality of life for patients. I certainly was and am. But most investigators don’t experience what patients do – except in cases like mine where researchers become patients and survivors. My experience certainly changed my perspective, which is why I want to share what I’ve learned with both the research and survivor communities.

That mission became more urgent for me today in the face of some jarring statistics. Tennessee and the surrounding regions have some of the highest cancer death rates in the United States.

Link to source.

Comparing the map above to the map below that shows new cancer cases diagnosed by state, incidence, the frequency with which cancer occurs, doesn’t fully explain higher death rates.

Link to source.

My heart sank when I saw these data, and really drove home my privilege. I am well-educated, have a high socioeconomic status, have access to insurance coverage and some of the best health care available in the United States, and I have inside information based on my work as a breast cancer researcher.

I’m lucky. Far too many of my fellow Tennesseans and Southerners are not. My Institution and Affiliated Cancer Center serve this region. I want to be a part of better serving patients in this region, which will be a HUGE focus of my advocacy work.

What will this work involve? One of the ways I think I can be of use is by helping recruit patients for clinical trials. According to what I learned today, many promising new drugs do not make it through Phase III clinical trial testing* due to failure to accrue enough patients to sufficiently test their effectiveness. That’s such a shame and missed opportunity. Of course, there are many barriers for patient participation in clinical trials – fear/lack of understanding; lack of access due to barriers to travel/transportation, unmet childcare needs, inability to take time off work, etc.; disparities that make minority populations reluctant to participate**. While I am not in a position to combat access to trials, I am in a position to serve as a liaison between patients and clinical researchers accruing patients for trials. I can help educate potential trial participants in the process, assure them of their rights (including the ability to stop participating at any time), alleviate fears through helping patients understand the benefits and how they might be helping a great number of future cancer patients. I am also working with African American advocates and other advocates of color to understand and be sensitive to those communities, their histories, and their needs.

Those needs are great, particularly in terms of breast cancer outcomes. African American women diagnosed with breast cancer have lower overall survival rates compared to white women. Finding out why is crucial for closing the gap. Increasing African American participation in clinical trials is a key part of that process.

Link to source.

For more on cancer disparities across ethnic groups, click here.

Bottom line: I’ve got work to do, and I’m excited to work with my fellow survivors to help patients now and in the future. Interested in becoming an advocate? Here are some resources that can help! My Institution’s Advocacy Resources, How Patient Advocates Help Cancer Research: Expert Q&A, Why Patient Advocacy is Vital.

*I’ll cover clinical trials in more detail in a future post. Click here to learn more now. Phase III trials test drugs that have already been proven safe and promising in terms of effectiveness.

**African Americans remember the horrific abuses perpetrated by scientific investigators, including those in charge of Tuskegee Study of Syphilis – which resulted in hundreds of African Americans being denied treatment in order to study the long term effects of untreated syphilis

Screw The Woo Woo: Essential Oils Won’t Cure Your Cancer

Essential oils. They’re EVERYWHERE! Articles and posts touting their alleged benefits are all over social media, some news media, and the Internet. A Google search I performed today yielded 1.7 billion results. 1.7 BILLION! Yup, there’s a LOT of buzz about the wonders and medicinal benefits of essential oils.

And almost all of it 100% certified Grade A Bullshit.

This post is dedicated to debunking one of my least favorite bullshit woo woo scams (second only to homeopathy). And I will do so with the power of science and snark, because that’s just who I am as a person.

So what are essential oils? They are oils purified from plants and carry the aroma of the source from which they are extracted. Their name comes from the fact that they are thought to contain the essence of their source, and they smell pretty good thanks to terpenoids, aromatic organic compounds produced by plants that often function as chemical protection against herbivores, insects, and microbes. They also serve as attractants for pollinators, seed dispersers, and in mediating plant–plant and plant–microbe communication. Humans enjoy them because they smell and in some cases taste really good. Sadly, allergies prevent me from enjoying the florals, but I enjoy herbals and fruit oils in a wide array of products – cosmetics, soaps, perfumes, lotions, bath products, and many food items. They’re just nice.

Fresh herbs and oils, wooden table background – we smell good and taste nice!

But do they have any medicinal value? What about medicinal value when it comes to cancer? Part of the issue with answering this question involves the (lack of) regulation when it comes to production and testing. The concentration of active chemicals in extracts can vary widely from plant to plant, which parts are processed (different concentrations in leaves, flowers, stems, and roots), which season the plants are harvested, which strains are sourced, etc. Without consistent batches subjected to quality control to assure consistent concentrations of active chemical components (like terpenoids), and without rigorous, scientific studies, we can only rely on anecdotal evidence and (often misleading) claims from suppliers. Some efforts are being made by the WHO for quality and safety evaluation of herbal products, including chemical fingerprint analysis*. Much like vitamins and supplements, which are not subject to the same rigorous FDA standards for safety and efficacy (how well it works) as drugs, essential oils fall under the category of “safe for their intended use,” which does not involve use as medical treatments. They’re considered safe until proven otherwise, a MUCH lower standard than FDA approved drugs.

More importantly, they are (by fairly low standards) rated for safety, but not for EFFICACY. That would require clinical trials and rigorous testing.

Should we be researching them? Sure! Some pre-clinical studies involving cultured cells (cells grow in a petri dish under laboratory conditions) and animal (primarily mouse) models have been published. A systematic review of the literature from 2014 to 2019 identified 79 studies that fit inclusion criteria – including studies investigating essential oils with anti-microbial and immunomodulatory (affects the host immune response) properties, nutrition studies, studies with controls and proper statistical analyses. Of those studies, many documented the anti-microbial (bacteria fighting) and anti-fungal (fungus fighting) properties, antioxidant properties that may help slow food spoilage, and anti-inflammatory properties in laboratory and agriculture models. And, in some preclinical studies, high doses of essential oils can kill cancer cells in culture in a laboratory setting. Does that mean they’ll do the same thing in humans? Not necessarily. See my post on turmeric.

Just for perspective, it’s pretty easy to kill cancer cells in culture in a laboratory setting. I once killed a dish by accidentally leaving the cells in phosphate buffered saline instead of growth media. Yes, salt water can kill cancer cells in culture. So can many drugs, but the majority of compounds with anti-cancer activity in cultured cancer cells and mouse models are not effective in human clinical trials. So, the jury is out on whether or not the active ingredients essential oils can help treat cancer. And inhaling the pleasing aromas produced by essential oils may effect mood, but it doesn’t do anything to thwart cancer growth, survival, or invasion.

These observations definitely warrant more laboratory investigation, but as of this post, there is no evidence that essential oils fights cancer when inhaled or ingested or delivered in any other way into the human body. Advertisements by scammers like the ones listed below are lies:

These are some of the top hits under a Google search for “treating cancer with essential oils.” As is my standard policy, I will not share links for woo woo. The misinformation and outright lies are not only infuriating, they can prove deadly for patients who skip standard therapies in favor of alternative “therapies.” The stats are heartbreaking. In a Yale School of Medicine study (link to original publication here*), “patients who used alternative medicine in place of standard evidence-based medicine had a death rate 2.5 times higher than patients who received standard evidenced-based therapies.”

Women with non-metastatic breast cancer who opted for alternative “medicine” were ~ 6 times more likely to die within 5 1/2 years compared to women who received standard of care therapy. This is a small study – 281 patients – and captures data from patients who disclosed their decision to follow alternatives versus standard of care. It doesn’t include patients who do not disclose or discuss this with their health care providers, so the numbers could actually be higher.

For more information on aromatherapy – separating fact from fiction – click here. Check out this article, too. Bottom line: much like cannabis, essential oils may offer relief from the side effects of standard of care treatments, but they cannot cure cancer nor should they be used as a substitute for standard of care. Complimentary alternative medicine is fine, as it compliments proven therapies, but not on their own.

*Access to this article is limited by a paywall. If you want to read it for yourself, hit me up and I’ll send the PDF.

Fixing Mistakes – Putting Action Behind My Big, Fat Mouth

Yesterday, I wrote a post about scientific fact checkers and how scientists interact with them, using Dr. David Sabatini as an example. I did NOT expect the attention it garnered, but I do hope that Dr. Sabatini (if he read it) took it in the spirit in which it was intended. Like I noted in the original post, I’ve been following and admiring his work on mTOR for years. Thank in part to his efforts, mTOR inhibitors are in the clinic and are helping cancer patients fight their disease.

As a scientist, I find that very intellectually stimulating and gratifying. As a cancer survivor, I’m eternally grateful. Should my disease recur, torkinibs may be a part of my treatment plan, or perhaps third or fourth generation inhibitors. There are more options now thanks to the efforts of laboratory and clinical investigators around the world, and that gives us all so much hope!

At the end of the previous post, I noted that I, too, had been flagged on PubPeer for an error in a 2012 publication. What happened? In figure 4C, we inadvertently duplicated photomicrographs in the top panels:

Yup – the sharp-eyed PubPeer reviewer caught what the graduate student, collaborators, myself, my co-investigator, peer reviewers, and the journal production editors missed. The “Parental” and “Vector” images are identical. Not good. Now, this is a relatively minor error, but if left alone, it could lead to the perception that our laboratory group is sloppy and not as rigorous as we should be. In science, like many other fields, reputation is everything.

How does this happen? It’s a product of long hours poring over data, trying to select the best representations of experimental results, building figures and revising them…and revising them…and switching out panels and photos until the student or postdoc putting together the figures eyes are crossing. Many of them are sleep deprived, overloaded, and after a while, really numb to looking at the same data over and over again. Is that an excuse? No, it’s a reason, which is why study PIs, collaborators, reviewers, and the journal have a responsibility to double, triple, and quadruple check our papers before they’re sent out into the cyberverse for other scientists to read.

I take my part of the responsibility for this one. At the time, I was a Research Assistant Professor. While not on tenure-track, I was quite senior in the laboratory and had a duty to co-mentor and support the graduate students and fellows in the lab. My name was on the paper. I missed this and dropped the ball. That’s on me.

Fortunately, thanks to PubPeer, I have the opportunity to fix it!

After sorting through electronic files (thank GOODNESS our former lab members were organized), I was able to locate original images and generate correct (distinct) panels for Parental and Vector controls:

Submitted to PLoS One as a correction

I contacted PLoS One today to request a correction. They may not re-issue the paper due to time and cost constraints, but I do hope they’ll add the corrected figure panels to an addendum. I’ll report back on this once I hear from them.

Bottom line: We ALL make mistakes from time to time. Yet, our culture discourages us from owning those mistakes, as if they’re a mark of shame or weakness. Certainly admitting mistakes has become uncomfortable and taboo. That is something that needs to change. Owning mistakes and fixing them are signs of integrity. When I’m entering into new collaborations, I pay attention to how my potential co-investigators and their team handle mistakes. Admission and ownership of mistakes and efforts to correct them are signs that new collaborators are trustworthy, rigorous, and have integrity, essential qualities in modern science. Very few scientific studies are performed by a single laboratory/person in that laboratory. Shared labor is the norm, so trust is key.

I WANT to be known as trustworthy, as someone with integrity whose work can be trusted and reproduced. As someone who recently withdrew a submitted manuscript when we (to our horror) found out that many of the data weren’t reproducible, I’ve become more vigilant. And I’m a better scientist for it. Science is better for vigilance. And that’s a good thing.

Being a Great Scientist – How to (and NOT to) Handle Mistakes

In the age of the Internet, trolls and trollish behaviors have multiplied exponentially. Science is not immune. Many of us were late coming to social media, but more and more laboratories, institutions, programs, scientific organizations, conferences, professional organizations, and journals are engaging in Twitter and other outlets. Overall, this is a great thing! It is so satisfying to peruse science Twitter and catch up on all of the latest findings, hot new studies and publications, and enjoy a community of peers that extends beyond the halls of individual institutions.

But OF COURSE there are trolls and trollish folks in the Twitterverse. Smart people aren’t immune to this. It’s human nature. Not our best quality as a species, but it’s there nonetheless and it extends to people across professions, educational backgrounds, political and religious ideologies…you get the idea.

No matter where you go, there’s always one (or more) assholes. That’s a fact of life, like death, taxes, and motherfucking reviewer number two.

A positive side-effect of the Internet Age is the rise of transparency and fact-checking. This is important in every field (side-eyes the news media), but especially in science. Scientists pore over the literature and build upon previous studies to move the field forward. If a study contains errors, inconsistencies, or (in the worst cases), fabricated or altered data, it undermines the integrity of the field and the scientific endeavor. That’s why sites like PubPeer work to spot inconsistencies in published scientific literature. Now, no one likes to have their mistakes posted in big bold font on the Internet, but setting aside ego and emotion, it’s actually a GOOD thing! It helps us be vigilant about our work and the work of our colleagues who contribute data to shared publications, it allows the authors of the studies in question to go back and examine the data and correct mistakes in collaboration with the journal in question. It makes science more rigorous. All good things.


Link to Meme

The scientist in question decides to get his or her TROLL on!

When a mistake is pointed out on PubPeer, there are basically two ways to handle it. #1 – Thank the fact checkers for finding the error, dig through the data and fix the mistake, contact the journal in which the mistake was published and (if possible) update the data presented or add a note with the updated data as an addendum, and promise to be more rigorous in the future. This is the best way to handle it. It preserves your integrity as a scientist (and the integrity of the scientific process), it shows your commitment to ethics and responsible conduct of research, and it shows that you value your reputation and quality of your work enough to protect it. Basically, it makes you look good, honest, trustworthy – all qualities you want to have as a human being and a scientist.

Link to Tweet

Then, there’s the second way to handle it…#2 – Insult the PubPeer fact checker (petty, failed scientists), block “steaming turd,” (grudgingly) contact the journal to see what you should do. See this post from For Better Science for the run down. The first two items are childish, unnecessary, and, well, trollish. Mistakes happen, even to the great and mighty Dr. David Sabatini (whose work I actually follow and admire, since I’m working on mTOR signaling in breast cancer in my own lab). He’s a leader in the field, and he could have used this as an opportunity to set a great example for his peers and colleagues by handling this situation, which happens to plenty of scientists, with grace, dignity, and integrity. Someone with his reputation and in his position has a great deal of influence and sets the tone for scientists at all levels.

This is not a great tone. This is not a good look. I’m 95% certain that, had he not gone on Twitter and got his troll on, no one would be talking about the errors that have been found in multiple papers. He could have quietly fixed them and moved on.

Instead, EVERYONE is talking about this. This isn’t the kind of publicity you want as a scientist. Here are some Twitter replies:

There are even more replies to the first post, some showing sympathy and support – while gently pointing out the importance of the work PubPeer is doing – others (who tend to get blocked) calling out Dr. Sabatini on the insults borne of ego. It didn’t have to go down like this. It’s sad and unfortunate that it did. Hopefully, it will serve as an example of what NOT to do when confronted with evidence of error in published work.

For a GREAT example of what to do when confronted with evidence of mistakes in a publication, check out how Nobel Laureate Dr. Frances Arnold retracted a published study when she and her colleagues found the results were not reproducible missing data from a lab notebook. This is a fantastic example of integrity, honesty, and ethics.

*Note – you might be wondering if I’m just armchair quarterbacking, safe in the knowledge that I’m not the one being called out by PubPeer. I am not. In fact, when I joined PubPeer and did a search on my name, I found a post about an error in a 2012 PLoS One paper for which I was a co-author – we accidentally duplicated a photomicrograph. These things happen, but I’m GLAD the PubPeer fact checker spotted it so we have the opportunity to correct this. We are working on it NOW!

(And yes, I did thank the fact checker, because my mama raised me to have manners)