Philip Kovoor, MD, oncologist at Baylor Scott & White Medical Center – Plano talks about a treatment for cancer prior to surgery.
Interview conducted by Ivanhoe Broadcast News in May 2018.
You said you do all kinds of cancer and do you specialize in breast cancer?
Dr. Kovoor: I’m a general oncologist who sees all different types of cancer, but breast cancer is an area of special interest.
We’ve talked to one of your patients. Go back a little more than three years when you saw her and what were your options when you helped to diagnose her cancer?
Dr. Kovoor: Three years ago when we started this journey Jenna came in. Because Jenna is a nurse, she felt like part of our family and had an instant connection. In her specific case we had an aggressive subtype of cancer that was locally advanced. Our options at that time was consideration of a combination of surgery, chemotherapy and radiation.
It seems like you opted for a treatment plan that started off with chemo. Tell us about that, why you went that way.
Dr. Kovoor: For patients with with aggressive locally advanced breast cancer, the general standard of care is neoadjuvant chemotherapy. Neoadjuvant chemotherapy is what we term for individuals that need chemotherapy prior to surgery and the purpose is to downstage the patient by making the tumor smaller. Now our goal, God willing, is to eradicate all signs of cancer so that by the time we get to surgery we can be cancer free. It helps us to do less surgery and to clear margins. In addition, it helps to attack any seeds of cancer that may have spread.
So I guess after you start the administration of the chemo then you also have to be able to monitor how it’s working right?
Dr. Kovoor: For monitoring purposes with the neoadjuvant chemotherapy, we work in tandem with our breast surgeons and our radiologists. We perform periodic exams in the office to demonstrate shrinkage of the tumor and response to the chemotherapy. In addition, ultrasounds and mammograms are routinely performed to validate response as well.
In Jenna’s case how well did the treatment work?
Dr. Kovoor: We had a significant response to neoadjuvant chemotherapy and she did very well during the treatment.
And then subsequently you or a surgeon performed the double mastectomy right?
Dr. Kovoor: Correct.
And then you get involved after that to do the radiation?
Dr. Kovoor: A medical oncologist is typically described as the primary care doctor of oncology. We help to coordinate care and typically we’ll do the long term follow up. So even if our breast cancer patients are five years removed from their surgery, we will still see them at least on an annual basis. We also help coordination with radiation doctors. We typically offer the systemic therapies as they apply to cancer.
The route being the chemo to reduce the size of the tumor and then the surgery and radiation and what happened after that.
Dr. Kovoor: If we didn’t embark on the chemotherapy up front, I think our surgery would have been more technically challenging. We would have run risks of two things. One, not being able to remove all cancer and to clear margins. This is very important. Our surgery is the curative modality of breast cancer care. Radiation and chemotherapy act as a supplement to enhance the statistical odds of remaining in remission. You want to give the surgeon the best possibility of doing a precise surgery that technically removes all spots of cancer and gives better outcomes.
The other thing is if you have locally advanced breast cancer and if you have cancer within the lymph nodes your lymphatics are the highway system to the body. It gives this cancer an opportunity to metastasize cells to other parts of the body. By giving chemotherapy up front we’re able to go after those sites of metastatic disease in the event that there are any seeds of cancer that might have spread.
Jenna told us that there were some indications on her liver or something that turned out to be false?
Dr. Kovoor: Yes, Jenna had an abnormality in the imaging that ended up being something benign. It had nothing to do with the cancer. But sometimes when we’re doing staging you have to follow things that may be normal variants.
What if you didn’t do the chemo, what could have been the outcomes?
Dr. Kovoor: I think that in Jenna’s case particularly if we didn’t do chemotherapy the statistical likelihood of achieving a cure would have been less. With the addition of chemotherapy we enhanced her chances of long term survival.
I understand cure, are we talking life and death here?
Dr. Kovoor: Absolutely. And in a setting of locally advanced breast cancer that has spread in to the lymph nodes this is the appropriate therapy. Historically, if chemotherapy was not pursued, mortality rates were higher.
You presented all of this to her right?
Dr. Kovoor: Correct. We went over pros and cons of chemotherapy, pros and cons of the different approaches, neoadjuvant chemotherapy with surgery, surgery followed by what we call adjuvant chemotherapy which is after surgery. One of the advantages of the neoadjuvant approach is we know what we’re giving is working. If you give chemotherapy after surgery we can’t objectively tell the patient, ‘this tumor is shrinking’. And so there is a strategic advantage of doing the chemotherapy up front knowing that objectively by measurement by ultrasound or a mammogram that this tumor is shrinking.
How would you describe her condition today?
Dr. Kovoor: I think she looks great. She’s that story we share with other patients and other survivors to give encouragement because you know when you go through the fire and you come out of it and you beat the cancer you know it’s something to cheer for, it’s something to offer encouragement to other people, it’s something to pay forward.
You tell me is she cancer free?
Dr. Kovoor: When we use the word cancer free, we base it on our blood testing, our physical exams and imaging findings, if done, and based on all objective evidence that we are cancer free.
How does that make you feel?
Dr. Kovoor: It feels really good. You know being an oncologist it’s an emotional journey and we have highs and lows but stories like this is what helps keep us going. And so we will welcome that any day of the week because it encourages not only me it encourages my staff. My nurse is very close to Jenna and when we see Jenna coming in vibrant and smiling, it just helps lift us up. Because you know prior to her appointment we may have had an appointment where we were talking about someone who is on hospice or who’s dying from the cancer. When you have someone that’s doing well and someone who has been through a lot, that’s the encouragement to keep us going.
She says that if she didn’t undergo the chemo she doesn’t think she would be here today. What do you think?
Dr. Kovoor: I think that chemotherapy in her particular case had a lot of benefits and a clearly defined role based on evidence. As far as mortality I think the only person that can really answer that question is the man upstairs. I pray to him but I don’t know if I can say that for sure. I think based on literature and based on evidence that we had given her the best therapy we could to give her the best statistical odds to beat it.
How unusual is her case?
Dr. Kovoor: I think anytime you have someone that’s young who gets diagnosed with breast cancer or any type of cancer for that matter, it always catches our attention. I think the longer I’ve practiced the more young patients I’ve seen with cancer. And so it’s still unusual to develop cancer under the age of forty but it’s feeling like it’s becoming more common place.
Any idea why?
Dr. Kovoor: My clinical feeling on this is I think it’s multifactorial etiology. I don’t think it’s just one thing. I believe it’s a combination of environmental and genetic risk factors. We’re continuing to explore to better understand genetic and environmental risk factors. But my personal feeling it is a combination of those two risk factors that play the biggest factor in developing cancer.
Assuming that the genetic risks are relatively the same as they were before this increase then that must mean the environmental factors are increasing.
Dr. Kovoor: we’re identifying more mutations than we have in years past. I believe these mutations existed, but we did not have the technology to detect them. In regards to environmental risk factors, I think that we expose ourselves to many things that are carcinogenic that we don’t realize.
I think when we go back fifty years ago or a hundred years ago there was less frequency of cancer, why is that? We have to look at how things have changed. Fifty years ago we grew all our food in the back yard. There are a lot of things in our foods and in our environment that I think can be potentially carcinogenic that probably play a factor in to why we’re seeing more rates of cancer. In my own life I try to stay as organic and clean as we can because I think that, that plays a factor in development of cancer.
So you buy organic?
Dr. Kovoor: I do buy organic, and I try to stay as holistic as I can. I try to stay away from processed foods as much as I can. I try to incorporate a healthy balance of fruits and vegetables and get thirty minutes of cardiovascular activity most days of the week. I think our first line of defense that God gave us is our immune system. And the way to strengthen our immune system is through sound mind, body and spirit.
There are some studies or they’re doing some studies and there are some people who are starting to advise against the chemo because of the side effects and because some people are saying it’s hurting quality of life rather than helping. Do you have an opinion on this?
Dr. Kovoor: Absolutely. I think we’re in an era of de-escalationo of how often we use chemotherapy. If you go back to the 1980s, the mortality rate of breast cancer was very high. Women of all ages were dying from breast cancer at high rates. In the 1980s, there was a big stigma of breast cancer because of the mortality.
And so what happened in that era is we said, ‘okay. people are dying — how do we help fix this problem because it’s a big problem.’ If you look globally, breast cancer is now the leading cause of cancer death globally. In the US it’s the second leading cause of death in women. And so it is one of the most common cancers globally and it has the highest mortality rate globally. So from there the oncologists and the scientists began to pursue aggressive chemotherapy modalities in the1980s. What we were finding was that people were getting sick but we were also reducing the morality there. But we didn’t understand the genetics and the genomic profiling of tumors. And so every patient of a certain stage or certain subtype were getting the same types of therapies. Then the era of transplant in the 1990ss began to evolve for treatment of breast cancer. The cost for bone marrow transplants was really high, but the morbidity and mortality rates were also high. And we eventually determined that this strategy was effective based on prospective studies. Then the pendulum swung again.
You were talking about how they started doing some other things that didn’t work and I guess in the process they were continuing to use chemo a lot. I guess they were just trying to figure out how chemo works.
Dr. Kovoor: From transplant we then switched the paradigm back to traditional chemotherapy. But it became the question of who would benefit. Early stage and locally advanced breast cancer received chemotherapy based on pathologic risk features. For example, high risk pathologic risk factors, included tumors over two centimeters high grade tumors, lymphovascular invasion, and lymphnode involvement. These high risk individuals were considered for treatment with chemotherapy. But in reality what we found out as the years went by with more prospective studies is that not everyone in that group necessarily benefited.
So the question became how do we identify these patients that really benefit versus those patients that may not benefit from these chemotherapy drugs. Can we save people from getting chemotherapy?
But on the other hand, we want to identify people who may not have historically received chemotherapy, but may benefit from it based on emerging data.
One of the first things that came out was ocotype, a twenty one gene assay looking at risk scores. These risk scores came in three different categories a low risk, an intermediate risk, and a high risk. For the low risk we knew absolutely that you didn’t need chemotherapy, so now we were able to supply some ammunition to do less. We were doing less chemotherapy with the advent of this technology. The higher risk we knew benefitted from chemotherapy and so these are the patients that we knew really needed it regardless of what we used to think about their pathology before. Then we had an intermediate risk. Now for the intermediate risk patient, we relied on a doctor’s discretion because we weren’t sure in that intermediate risk category who would actually benefit. In the intermediate category we would have an informed discussion about the pros and cons about chemotherapy and pathologic risk features.
Then additional research led to the development of MammaPrint, which is a seventy gene assay genomic profiling technique. With MammaPrint there were two risk scores, either high risk or low risk. So the high risk patients were considered for chemotherapy and the low risk patients did not receive chemotherapy.
De-escalation in my mind is using better technology, genomic profiling and a better understanding of patient risk factors for the administering of chemotherapy. With a better understanding, we are offering chemotherapy to less patients, and giving it to others who may not have received it in the past.
Is chemotherapy overused?
Dr. Kovoor: No, I think if it’s used in the right context with evidence based medicine and the right guidelines, we are giving it appropriately and saving lives. In addition, with the new technologies we are giving less chemotherapy than we ever have.
So do you find in a quantifiable way are you prescribing more or less chemo these days?
Dr. Kovoor: I practiced for at least the last ten years and I would say from ten years ago until now we have become smarter. I give less chemotherapy than I did ten years ago.
However in the case of somebody like Jenna you a hundred percent think the chemo is appropriate?
Dr. Kovoor: Absolutely. So Jenna’s case a few years back it was the standard of care. It was considered if you look at our National Cancer guidelines a category one recommendation by our National Cancer guidelines. If you fast forward today, those same recommendations are still considered category one recommendations. So Jenna’s chemotherapy recommendations would be the same today.
When you said overall you’re probably doing a little less chemo than you were maybe ten years ago, so give me a short answer if I say why?
Dr. Kovoor: I’m going to talk about breast cancer and the reason why we give less chemotherapy because we’re understanding the biology better. And we know who exactly benefits more and who doesn’t. I think because we know better who benefits from it, we’re using less chemotherapy as a result.
From her point of view she believes the chemotherapy was very important and probably saved her life. Her view was like five months of side effects or suffering was all worth it because now she has her whole life ahead of her. Is she right?
Dr. Kovoor: Absolutely. So for Jenna’s case I could project myself in her shoes. She’s a healthcare worker, and I’m a healthcare worker, I have young kids, I have a wife and at the end of the day when you’re young and you’ve got young children as a father, as a mother you want to be there for them as long as you can. I want to practice with evidence. If I can get a better statistical odds of getting a cure, I’m absolutely going to pursue that for myself or my wife because I want her and myself to be there as long as we can for our children that need us.
There was an article in the Wall Street Journal it quoted a couple of doctors who were more or less saying maybe chemo is overused. So if you’re just John Q citizen I’m sure a lot of people read this article or articles like this and they’ve become very confused. So how do you help them to get through all this?
Dr. Kovoor: The Wall Street Journal article on the different opinions about chemotherapy overuse or underuse, focused mostly on overuse and how we talk with patients about chemotherapy. ,. And I think it’s just being informed about it what chemotherapy is and the right circumstances to use it.
If you use the new technology and the current national guidelines, chemotherapy will be given and withheld in the appropriate situations.
So let’s say getting back to using your methodology let’s say if I’m Jenna talking to you and we know what’s going on here, and if I said to you what if I was your wife what would you do?
Dr. Kovoor: Asking the question – if this was my wife what would I do? I’m going to answer that two ways. One: I dealt with cancer in my family before I was an oncologist. My first cousin was diagnosed with brain cancer at the age of sixteen. I was always a science and math person and I just remember hearing what the doctor’s had to say, not always following everything but feeling overwhelmed. When I left that situation I wanted someone to explain this clearly, explain this compassionately and help me understand what’s in front of me.
Well I see my patients as an extension of our own family here and in our clinic. If you think about this as one of the greatest commandments in the scripture, “to love your neighbor as yourself.” If you love your neighbor as yourself, then you want to be able to project what you would do in that same situation if this were you. If you were to do that, you sleep well at night, And at the end of the day if one can see that honesty or sincerity in what you’re recommending then it can help the patient make decisions.
So if Jenna was your wife would you have recommended the same thing that she did?
Dr. Kovoor: If my wife had the same cancer diagnosis as Jenna I would have done the exact same thing.
I’m sure you have encountered people who get these diagnoses and they want to go like all natural. They may not have eaten very well until they got to this point but now they want to go organic and totally natural. What do you tell them?
Dr. Kovoor: So how do I respond to patients that want to go completely alternative or all natural or all organic? There are different extremes. I come from a homeopathic background. I have a lot of family members that pursue homeopathic medicine. I come from a background like that so I understand that line of thinking and the merits. However, I have never seen this modality of medicine cure cancer. I think natural methods can complement traditional treatments.
What about the person that comes in and somehow maybe it’s pancreatic or something and they say, well you’ve got three months to live. And they say, well I don’t want to go through any more tests I’m just going to go on vacation, what do you tell them?
Dr. Kovoor: If someone comes in with a terminal diagnosis with three months to live, and they have choices of palliative chemotherapy versus enjoying their time and being with family and loved ones. So what I would say is it depends on a person’s circumstance, I’m there to support them. If it’s terminal, chemotherapy is palliative in that setting. We’re trying to is extend life with quality. If one says, ‘look I don’t want to go through that and risk those side effects to each his own,’ and I would completely support them unequivocally.
It sounds like this whole debate that apparently is happening would you agree that there seems to be a dialog at least about whether chemo is overused these days? Or is it hype?
Dr. Kovoor: I think the debate over whether chemo is over used is hype. I think its headlines to some degree. I think at any given time in medicine we’ve used evidence to support what we’ve recommended. FDA approved drugs I just think are wiser. And you know as medicine gets wiser and smarter we’re getting more precise.
I’m going to give lung cancer as an example. I remember when I was training we used to do the same paradigm for lung cancer. Any type of lung cancer it didn’t matter the biology you do number one, whenever number one didn’t work there was number two, and whenever two didn’t work you did number three. And I remember this for the boards and you go in and after that it’s either clinical protocol or you go in to hospice.
But we’re so much wiser now than we were then. And now if you look at it we’re looking at all these different biomarkers for lung cancer. We have multiple different options and it’s no longer cookie cutter like it used to be. I just think we’re getting smarter. And we’re giving things like immunotherapy, targeted therapy that have less toxicity and have better outcomes. People are living longer. If we go into pancreas cancer, I’ve got patients that are now five years survivors of pancreas cancer where we didn’t see that in years past. And why is it? It’s because we’re becoming wiser and smarter about how we’re implementing our technology and learning more about the biology of cancer.
And certainly early diagnosis helps.
Dr. Kovoor: Early diagnosis is a means of detecting cancer early. Specifically with mammograms, ultrasound, MRIs, 30-D mammograms and tomosynthesis, we’re diagnosing breast cancer at a much earlier stage. And in those situations you won’t need me in the sense of chemotherapy. We might need endocrine therapy which is gentler and easier but in these situations we’re saving lives and we’re avoiding chemotherapy.
In terms of this particular story is there anything else that we haven’t touched on that you might add?
Dr. Kovoor: I want to speak to chemotherapy. I think there’s been a lot of bad press about chemotherapy. I think there’s a lot of bad stigma. You know one of the common concerns is hair loss due to chemotherapy. Or someone may think they will be vomiting and hovering over the toilet for the next three weeks. People may think they will not be able to work or do the things they enjoyed previously.
With the advent of supportive care and better anti-nausea medications, I have patients that are working full time, balancing their life and still able to do the things that they enjoy doing. We want to preserve life and we want to preserve quality of life. I’m not saying that chemotherapy can’t have its challenges because it certainly can. But if it’s used in the right setting, I think the oncology community as a whole, is saving lives. If you look at breast cancer mortality from the1980s to what’s been reported here after 2015, there’s been a almost forty percent mortality reduction in breast cancer., This mortality reduction is a direct result of a better understanding of the biology of cancer and improved technology.
Does endocrine therapy have to do with trying to prevent the spread to the lymph nodes?
Dr. Kovoor: Correct. So endocrine therapy is using estrogen blockers. And estrogen in some subtypes of cancer can stimulate the production and development of breast cancer.
She mentioned that you induced menopause with her, was that a type of endocrine therapy?
Dr. Kovoor: Absolutely. Inducing menopause in someone who is going under neoadjuvant chemotherapy with locally advanced cancer helps to fight the cancer in a different way. So chemotherapy, traditional chemotherapy for breast cancer is attacking the way cancer cells divide. It’s the way DNA replicates. But you also want to think about how can you block off the feeding mechanism. So if it’s estrogen receptor positive, the estrogen that your body makes helps feed cancer. If you’re able to suppress your estrogen, or suppress the ovaries you are now helping reduce the cancer’s potential food supply. It allows or improves pathologic responses to neoadjuvant chemotherapy.
I guess for her it all added up to a good result?
Dr. Kovoor: Absolutely.
END OF INTERVIEW
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