Transcription:
NorthShore Pathology: On the Cutting Edge of Breast Cancer

Melanie Cole (Host): We hear so much in the media today about genetics and your risk for breast cancer. What does that really mean as far as your risk is concerned? And if you do have to have some kind of a biopsy, what do those results mean? It can be very confusing and very dizzying. My guest is today is Dr. Karen Kaul. She is the chairman of the Department of Pathology and Laboratory Medicine at NorthShore University Health System. Welcome to the show, Dr. Kaul. So I would like to start just by asking you, what do we know about heredity and breast cancer?

Dr. Karen Kaul: So, Melanie, thank you for having me on the show today. And I’d like to actually start by commenting on genetics because I think this is a very confusing area for patients and for physicians. There are two somewhat different areas in genetics. One is the germ line, what we inherit through our families. And when we look at those genes, we are talking about hereditary cancers, hereditary diseases. And we generally test those on blood samples, and those results are interpreted in conjunction with genetic counsellors and medical geneticists. The other area that we focus on in the field of pathology is the genetics of a particular tumor, where we’re actually looking at acquired defects in the DNA that we now understand causes tumor formation. And actually, we study that by looking at the DNA of the tumor itself. And this has great importance, we are learning, in terms of determining how to best treat a patient for that particular tumor. And this is leading us all into the area that we’re hearing a lot in the news today, personalized medicine, where we can actually target a molecular defect in the tumor with a particular new drug. So, very different areas, and they’re approached differently. But for breast cancer or other cancers, these are becoming increasingly important.

Melanie: Are you seeing in your practice more and more people getting tested for their genetic risk?

Dr. Kaul: I think that's going to be a huge area of growth and an area where we need to understand a lot more about our germ line or hereditable genetics. Breast cancer is one area where we know that there are a couple of genes—namely BRCA1 and 2—that cause a percentage of tumors. And by looking at a family, looking at an inheritance patterns of cancer with that particular family, we can identify who is likely to be at risk and specifically test those patients for mutations, alterations in these genes and predict who is likely to get cancer. This was in the news a lot last year with Angelina Jolie coming out very publicly about her experiences. We are also beginning to understand that other genes are important as well, and there’s been a great deal in the news of late about other genes besides BRCA1 and 2 that we may want to look at in certain populations of patients so that we better understand their overall risk. So this will no doubt continue to expand, and our knowledge will grow, and it will probably become more complicated. And the field of medical practitioner called medical genetics is going to become increasingly important in years to come.

Melanie: What a fascinating field of study, Dr. Kaul. It really is. So, if someone gets tested or doesn't get tested, or if they are found they have a lump and they get a biopsy, this biopsy, this is where everybody kind of loses track here and what happens. The biopsy is sent to a pathologist such as yourself to analyze the tissue and find out whether this is a malignant tumor or not. Tell us what happens in your department that will help us to understand what’s going on.

Dr. Kaul: So first, just a bit if I may about pathologists because we are very much behind the scenes. We rarely interact with the patients. But occasionally, patients get bills from us because we do interpret results on their tumors, on their blood tests, and other things. So, pathologists are responsible for a very large portion of the decision-making process in patients because we generate all the answers in the lab that guide the clinicians, the physicians to know how to best treat their patients. But it is a bit of a mystery because we’re not out front and center in front of the patient. In the case of a tumor, breast cancer—or other tumors, for that matter—generally we start with a biopsy. This could be because there is something funny-looking on your skin, or in the case of breast cancer, because there’s a suspicious area on a mammogram or a lump that can be felt on breast exam or what have you. And usually, the way this will start will be a biopsy. In the case of breast cancer, this would typically be either a needle biopsy or an aspiration of cells out of the mass that is, again, directed sometimes radiologically and with use of a needle. And the material that comes out would either be a small portion of tissue or cells that are smeared on the slide, and this is going to go come up to pathology to be examined by a professional who can look at the material on the slide and determine whether it is normal, suspicious for some reason, or clearly malignant. And what we generally will do is look at the cells that we see in the tissue, and we’re trained through the years of our training to identify what is going on with these cells and classify the results accordingly. Most of the time, fortunately, our answer is that this is a mass that is not suspicious for cancer and the patient can be reassured. Sometimes there requires more material to come to a definitive diagnosis, and other times it’s very clearly cancer. And that will set the patient on down subsequent work up and treatment planning with their oncologists. The process generally at this point in time starts with microscopy. We put material on a glass slide and look at it under the microscope. This process takes a few days to complete processing the tissue and making slides, et cetera. Sometimes, we have to do additional studies on that material. Immunostains for expressing different proteins or sometimes actually looking at DNA defects in the genes present in that tumor to come to a full diagnosis. So, there are a few days that pass by between the point in time that a biopsy is taken and the time that a result is available for a clinician to begin treatment planning.

Melanie: And Dr. Kaul, when you are delivering these results in the form of a report, which then goes to the patient, is this involved in this staging process too? Are you the one who determines how invasive this cancer is or what stage it has progressed to?

Dr. Kaul: To a certain degree, yes. So, generally, our reports will go to surgeon, a clinician, medical oncologists, and they will be reviewed with the patient. So we add to the collective information that is available on that patient. We do pathologically stage patients, which means that we look under the microscope and see if we can be certain that a cancer is in situ, meaning it has not begun invading, which obviously is a much better prognosis for the patient. Or if we can see microscopic evidence of invasion, we’ll document that. In some cases where lymph nodes are removed as part of a resection—this obviously is beyond just a biopsy stage—we’ll examine the lymph nodes and try to identify whether the tumor has spread to that part. And that generally will lead to a difference in the treatment approach used in that patient. Additionally, staging can include information from radiology. Patients might be screened in other ways with other methods in radiology, a CT scan or what have you to try to add information to the overall staging. But pathologists do contribute a lot of this information on actually looking at the tissues.

Melanie: And does the cancer itself have genes that affect how the cancer might be treated? Can you tell that in your report?

Dr. Kaul: We are beginning to look more and more at this not only in breast cancer but in lung cancer, colorectal cancer, melanoma, thyroid cancer. I think this is an area where we are going to have a huge impact upon how patients are treated in the future. Historically, cancers were classified according to the organ in which they originated, hence you have breast cancer, lung cancer, and what have you. I think the next level of classifying cancers was how they look under the microscope. So we have a whole series of pattern recognition type of classification that pathologists would use—the cancer is ductile or lobular or tubular or what have you based upon how we see this under the microscope. And that added a certain level of information that sometimes reflected how patients would respond to treatments or how they would do down the road. But I think what's happening currently—and we’re in the midst of perhaps even a revolution in medicine—is we’re beginning to understand that what we can identify at the molecular level, at the gene level, really has a big importance in terms of how a patient is going to do and how they’re going to respond to treatment. And so, we’re beginning to look at cancers not just based upon the organ of origin or how they look under the microscope but what specific genes are altered in those tumors. Is this a tumor that is, for example, the result of a mutation in a gene like EGFR? These all have funny names that we understand but are probably alphabet soup to the general public. But we are identifying different pathways that can be radically altered by mutations and genes, and this in turn dictates how the tumor will best respond to a targeted therapy. And I think this is an area of great advancement and great excitement in treatment of cancers across the board, including breast cancer. But it will lead to us having to look at cancer in a very different way, will require that we get into studies that involve looking at these genes, like sequencing, and will require the medical community to look very carefully at how they determine what sort of treatments they can use for patients. And in turn, I think the insurer community and the FDA will have a look at what they permit patients to be treated with in order to optimize this entire system. So, big changes ahead.

Melanie: And Dr. Kaul, in just the last minute. Please tell the listeners your best advice for figuring out their pathology report and why they should come to NorthShore University Health System for such quality testing.

Dr. Kaul: Well, I think that discussing their pathology report with the surgeon or internist or oncologists, whoever they have worked with, is a great first step. We often meet behind the scenes with these people, present cases in joint conferences where we discuss appropriate management and bring in the most current and cutting-edge techniques like next Gen sequencing and other approaches to really make sure that we are getting the most detailed and appropriate information to ensure that patients are going to get optimal care. I think questions can be answered by the primary care physician or, more importantly, the specialists. And in some cases, it may be that they won’t even to talk to the pathologist. I think in some centers we’re seeing that pathologists are getting involved in helping to translate this complicated information to the patients. Here at NorthShore, we have actually started an oncology clinic to help patients understand these complicated results. And that is, I think, a huge step forward for patients to fully understand how’re being treated and why. And that’s something that’s new at NorthShore just in the last few months.

Melanie: Thank you so much, Dr. Karen Kaul. You're listening to NorthShore Health and Wellness. And for more information you can go to northshore.org. That’s northshore.org. This is Melanie Cole. Thanks so much for listening. /AT/rj/es