ONCOLOGY talks with Dr. David Mankoff, professor of radiology, medicine, and bioengineering in the department of radiology at the University of Washington in Seattle. Dr. Mankoff will be one of the co-chairs at the upcoming ASCO session on molecular imaging in cancer clinical trials, and he gives us a preview of what some of the highlights of the session are likely to be, as well as some insights into his own work.
ONCOLOGY: While your work is not directly in this area, can we get your opinion on the topic of breast cancer screening as a whole—we know that the recommendation is that people who are 40–49 no longer need annual screening, yet a newer study has said that annual screening finds breast cancers earlier and can result in more effective treatment.
MANKOFF: I would first like to make the caveat that I’m not a breast imager and my research isn’t really centered around screening. That said, this is a very confusing and controversial area. The recommendation reviewed studies and some epidemiologic data that were available and came to a different conclusion than had prior recommendations, and I think in general this is an area where there is a fair number of reasonable arguments on both sides. This has become a very individualized decision point for women and their physicians. One of the things that will help is more data, and another is having a better idea of factors that lead to a patient’s risk, because those patients who are at a higher risk for developing early breast cancer are the ones who will benefit from better screening. As a matter of fact there are already recommendations in place for women who have enhanced genetic risk to get screening, with MRI in addition to mammography. Ultimately I think that as we learn more about risk factors and how these techniques perform, we’ll be able to make a better recommendation.
ONCOLOGY: What are the areas of breast imaging and screening in which there are the most exciting new developments?
MANKOFF: I want to start by separating screening and breast imaging, because I think we’re traditionally used to thinking of breast imaging as something we do for cancer detection and then cancer diagnosis. These are areas in which I think there’s been a fair amount of progress in the past few years, in better understanding of how mammography works and some of the newer, digital mammography techniques, the advent of some advanced techniques such as tomosynthesis and the development of other modalities, especially breast MRI and more recently some of the nuclear modalities. I think there have been some very good prospective clinical trials that demonstrate the value of mammography and of breast MRI in high-risk patients and some interesting early data in breast cancer diagnosis with some of the radionuclear breast imaging techniques, but these are at a fairly early stage of clinical trials, and I think as the data emerge it will become a little bit clearer how to use those.
One of the other areas that I think is relatively early in development and not in the clinic yet, is the idea of using more molecularly based techniques to not only detect and diagnose breast cancer, but to help characterize it and to help direct appropriate treatments, based upon everything from how aggressive we think the cancer is likely to be, to how it’s biologically composed. Those techniques are just in the early stages of development but I think—especially since this is the area I work in—some of the most exciting developments coming down the pike.
ONCOLOGY: You’re touching on the specific work you’ve done, say, in the area of endocrine therapy for breast cancer, and the paper on glycolysis you published late last year in the Journal of Nuclear Medicine?
MANKOFF: Yes, as one example of this. I think that through a variety of techniques, including things like PET and some of the advanced MRI techniques and some techniques that are coming down the pike in optical imaging and molecularly targeted ultrasound imaging, there will be a whole host of things that will not only be able to detect breast cancer but to characterize it, and characterizing it I think will be very helpful in developing approaches that are individualized and molecularly targeted. So we’re at an early stage in that development, but it’s a very exciting stage.