Developing a Passion for Treating and Advancing Breast Cancer Care

Tiffany A. Traina, MD, FASCO

Sherry Shen, MD

The drive and motivation behind working towards a cure and maintaining the best possible quality of life for those with breast cancer can be summed up in 1 word for Tiffany A. Traina, MD, FASCO, and Sherry Shen, MD: passion. The 2 physicians highlighted the shared passion powering their journeys to become breast oncologists in the most recent Breaking Barriers: Women in Oncology program.

Traina, the vice chair of Outpatient Operations and section head of the Triple Negative Breast Cancer Clinical Research Program, and Shen, an assistant attending physician, both of Memorial Sloan Kettering Cancer Center (MSK), have had different experiences in the field. Whether that be surrounding the type of research they are conducting, the way the 2 discovered the “perfect” work/life balance, or how they both became involved in oncology, 1 thing is prevalent: their focus and dedication is on their patients.

Throughout the conversation, Traina and Shen exchanged ideas and life advice in an effort to help one another but also gave guidance to those who are just beginning their careers. When asked about the most exciting part of their careers, Traina said, “I would hope that I haven’t yet had the thing I’m most excited about happen. I’m excited to look forward to what’s coming.”

Highlighting Interests and Key Research Advances in Oncology

The conversation began at the beginning of their careers, and included what made them decide to become oncologists, and eventually specialize in breast cancer. For Traina, her mother was diagnosed at a young age with breast cancer. She noted that cancer was something she grew up around, and when her mother died from the disease, she wanted to make working in this field her life’s mission.

Shen’s interest in oncology drove her to the breast cancer space where she wanted to be part of the many treatment advancements that are happening in the field. Breast oncology is one of the areas that focuses on the personalization of treatment, so for Shen to be able to sit down with her patients and develop a care plan tailored for them is very special.

“It’s a privilege to be involved in their lives,” Shen said regarding her conversations with patients about personalized treatment options and their quality of life.

As Shen focused on her research, she became interested in the niche area of metabolic dysfunction among patients with breast cancer. Throughout her residency and fellowship, she worked closely with Neil M. Iyengar, MD, associate attending physician at MSKCC and co–editor-in-chief of ONCOLOGY.

She highlighted a recent study, of which she was the lead investigator, focusing on the development of hyperglycemia after the use of alpelisib (Piqray) in patients with metastatic breast cancer. Shen noted that hyperglycemia may cause dose reduction or treatment discontinuation of a drug “that we know works well”.

Of the 247 patients analyzed in the study, 61.5% developed any-grade hyperglycemia, and 29.2% developed grade 3/4 toxicity.¹ The median time to onset was 16 days.

“We found quite high rates of hyperglycemia that were higher than were reported in clinical trials, but also importantly, we identified baseline hemoglobin A1C, and [body mass index] as risk factors for developing hyperglycemia and treatment. This [study] hopefully allows oncologists to plan well ahead and work on those risk factors before patients [receive alpelisib],” Shen said.

Traina’s main area of interest is triple-negative breast cancer (TNBC). She highlighted that over the last 5 to 10 years, there have been significant advances in understanding the heterogeneity of the disease. Based on research that began at MSK, Traina and her team including pathologists, identified a subtype of TNBC that has a hormonal signature driven by the androgen receptor rather than estrogen or progestogen.²

“We led a couple of smaller phase 2 studies, and eventually a larger international phase 2 trial looking at the drug enzalutamide [Xtandi]. I’ve been able to lead the arc of that development as part of a team that is now conducting a multicenter trial, a randomized study through the [Translational Breast Cancer Research Consortium] looking at enzalutamide vs standard of care chemotherapy vs enzalutamide with another drug mifepristone,” said Traina.

The phase 2 study (NCT06099769) began accruing in October 2023 and investigators plan to enroll 201 patients with metastatic breast cancer.³ In the enzalutamide monotherapy arm, patients will receive 160 mg/day once daily by mouth; in the combination arm, enzalutamide will be given 120 mg/day by mouth and mifepristone at 300 mg/day by mouth; the chemotherapy arm will be investigators choice and may be one of a variety of regimens including eribulin, capecitabine, paclitaxel, or carboplatin at area under the curve of 6 or 2.

Although Traina has been in the field for a while, she noted that these advances do not happen overnight; she noted that, rather, “science takes a while, these advances take a long time.”

Watching the Field Evolve

While the research is constantly advancing, communication and collaboration need to be as well. Traina mentioned that involving translational scientists in preclinical observations and partnering with academic institutions and pharmaceutical companies have “fast-tracked” the science to make it impactful for the patients. The term multidisciplinary care is now being embraced more, which allows for better, more involved collaboration.

Biomarkers have become more relevant in recent years and can help researchers refine treatment and create clinical trials to help different populations.

Shen highlighted the excitement around developments in treatment personalization. Previously, treatment had been focused on escalation, but Shen believes the field has entered an era of de-escalation, which has helped with refining treatments and using clinical pathology and genomic characteristics.

“It’s exciting to both use [treatment personalization] to balance toxicities and efficacy and pioneer these new treatments in our field,” said Shen.

Traina chimed in that clinical trials have also become more diverse, as clinicians want to represent the populations they care for. Diversity in clinical trial populations has become a true priority across the board, along with making sure that diverse populations can receive these treatments with the intended effects.

“Historically, our clinical trials did not recruit ethnic diversity, older patients, and even a diversity by gender. There was a lack of being able to necessarily extrapolate the results that we saw from some of those early studies to the patients that we were treating in clinic,” she said.

Currently, Shen is involved in an initiative at MSK for lobular invasive breast cancer. Typically, it is lumped in with ductal carcinoma, which is more common. There are no trials involving lobular invasive breast cancer, so Shen and her colleagues are looking into developing them.

While treatments with various drug combinations is a major focus, clinicians should also be considering alternative therapies. The use of naturally occurring substances, supplements, and acupuncture may show a benefit for anti-cancer treatments and supportive care, according to Traina.

Finding Supportive Mentors

The conversation transitioned from their clinical backgrounds to the topic of being a woman in oncology, and whether there were any challenges they may have faced throughout their careers. Traina said she surrounded herself with mentors whom she called “gender blind”, as they were there to nurture and educate her passion and interest in the field of oncology.

Traina emphasized the need for multiple mentors to help with personal and professional development. For different areas of her life, she had a different mentor to help her navigate it including academic development and how to juggle life as a physician, partner, and mom.

Traina’s mentors included Larry Norton, MD, senior vice president, Office of the President, medical director of Evelyn H. Lauder Breast Center, and Norna S. Sarofim Chair in Clinical Oncology; and Clifford A. Hudis, MD, a consultant at MSK and chief executive officer of the American Society of Clinical Oncology (ASCO), both of whom helped to nurture her interest in the field of breast oncology.

Shen, who has spent the entirety of her career at MSKCC, said the environment there has always been warm and welcoming. She has rarely experienced external barriers as much as internal ones that she has created for herself.

“Some things that I’ve struggled with [are based on the way] we as women grow up and are raised. For example, speaking up in meetings where I felt like my expertise as a junior faculty attending [physician] was not at the level where I had a meaningful contribution to make. That’s something I’m working on, internally. Over time I have become more confident speaking up, [and tearing down] those sorts of barriers that I’ve encountered,” Shen said.

Several professional organizations have also created programs to help women in oncology develop their careers. ASCO and the Association of American Medical Colleges have developed educational platforms for women in medicine and emerging leaders.

Traina noted that these organizations circle back to what Shen mentioned about learning to advocate for oneself. “These are skills that can be learned, and we should be afforded that education alongside what we’re learning about drug development and science,” she said.

Shen highlighted that there are many female oncologists trying to navigate their careers and families who also struggle with these internal barriers. She found their support helpful in understanding and helping to make her own personal and professional decisions.

For Shen, her mentors Iyengar and Komal Jhaveri, MD, FACP, section head of the Endocrine Therapy Research Program, clinical director of Early Drug Development Service, and Patricia and James Cayne Chair for Junior Faculty, were both there to help with the research of metabolic dysregulations in oncology and assist with the work/life balance.

Managing Work, Life, and Everything in Between

When asked how they manage so many priorities, Traina recited a story she had heard from a senior female surgeon during a session on Women in Medicine session at a conference she attended. The surgeon had grown up with the expectation that dinner needed to be on the table every night, and mother was the one to prepare it. However, as her career developed, she learned to absolve herself of any guilt and realized she didn’t need to be the one to make dinner every night as long as the family could connect each night over a meal.

“It was liberating to hear, that it’s like a light bulb went off to say, ‘That’s right. I don’t need to be the one doing everything’. We need to understand what’s most important, and what’s most important is the relationship and being present. [We need to learn where to] delegate where possible, and not be shy about asking for help,” said Traina.

Shen emphasized this point and expanded that there has been a societal norm created that assumes men are ambitious with their careers, and women have to learn how to balance raising children, managing a household, and their jobs. Shen believes that this can create a lot of guilt for women as they’re pulled in many different directions.

Traina said her patients help to remind her of what’s important in life and what is a priority. There is only so much time in a day, and not everything can be accomplished.

Shen also mentioned that at the beginning of her career, she felt she had to be on top of everything and be detail-oriented. She consistently tried to figure out a balance between patient care and research, while answering every email straight away to show that she cared.

“I wasn’t relying as much on the wonderful team members that we had, because of the way we’re raised as women to be so detail-oriented and comprehensive and taking care of everything. I’ve realized that by relying on these team members a little bit more, I could accomplish more in other spaces,” Shen said.

In her closing remarks, Traina noted how much support she and Shen received at MSK and in the breast cancer community. They are consistently surrounded by supportive patients and a care team. She describes it as a “warm” field and hopes to propagate the culture further.

As Shen further develops her career, she has found amazing examples of women in oncology who have leadership positions at the institution she has surrounded herself with saying, “It’s nice to see that and so it’s something that I know that is achievable and that we can emulate.”

References

1. Shen S, Chen Y, Carpio A, Chang C, Iyengar NM. Incidence, risk factors, and management of alpelisib-associated hyperglycemia in metastatic breast cancer. Cancer. 2023;129(24):3854-3861. doi:10.1002/cncr.34928
2. Memorial Sloan Kettering Cancer Center. A phase 2 study of enzalutamide, enzalutamide plus mifepristone, or chemotherapy in people with metastatic breast cancer. Accessed May 15, 2024. https://shorturl.at/ewNQ3
3. A study of enzalutamide, enzalutamide in combination with mifepristone, or chemotherapy in people with metastatic breast cancer. ClinicalTrials.gov. Accessed May 15, 2024. https://shorturl.at/nzMW6