T H E J O H N S H O P K I N S K I M M E L C A N C E R C E N T E R

BREAST MATTERS[Inside]

UNDER ARMOUR CENTER OPENINGGILLIAN’S STORYASK THE EXPERTAND MUCH MORE

2018/2019

page 8A Patient's Best Friend

2018/2019 • BREAST MATTERS 1

T H E J O H N S H O P K I N S K I M M E L C A N C E R C E N T E R

BREAST MATTERS2018/2019

Facebookfacebook.com/Johns.Hopkins.Medicine

Twittertwitter.com/HopkinsKimmeltwitter.com/BloombergKimmel

Youtubeyoutube.com/JohnsHopkinsKimmel

PodcastCancer News Review: bit.ly/cancernewsreview

BlogsCancer Matters (timely topics)cancer-matters.blogs.hopkinsmedicine.orgOur Cancer (for caregivers)our-cancer.blogs.hopkinsmedicine.org

CONNECT!

On the Cover: Patient illustrations that capture patients engaged in physical activities werecreated by French graphic designer Florian Nicolle.

page 6Tailored Therapies

UPCOMING EVENTS Caregiver WorkshopNov. 3, 2018, 9 a.m. to 12 p.m.

Integrative Medicine WorkshopOct. 23, 2018, 11:30 a.m. – 1 p.m.

Support Groups, and more on page 12

page 3Under Armour Breast HealthInnovation Center opens

WEB EXCLUSIVE: Cancer Matters podcast with Vered Stearns,Elissa Bantug, and Bill Nelson bit.ly/2oKFnuw

2018/2019 • BREAST MATTERS 32 BREAST MATTERS • 2018/2019

It wouldn’t have been possible with-out Under Armour, Stearns says.

“Working with Under Armour,we were able to integrate wellnesswith breast cancer care fromdiagnosis to after treat-ment, creating an un-paralleled experiencein a peaceful and motivating space for our breast cancerpatients,” says Stearns. “A cancer education room offersvideos, print materials,seminars on breast health,nutrition and healthy lifestyle thatcan be shared worldwide through social media.”

The Under Armour Breast HealthInnovation Center also offers a num-ber of unique features, not the least ofwhich is its beautiful window-filledspace with panoramic views of theBaltimore skyline. A physical medi-

for realistic, 3D nipple tattoos that incorporate every anatomical detail—to patients completing their breastreconstruction process.

“Kevin Plank [Under ArmourCEO] tells us to dream big and neverforget our mission,” says Ullrich. “Somany Under Armour teammates wereinvolved with the planning and designof this space, and we thought aboutthe entire experience, from the floorto wall coverings and photos to thecolors and even the chairs.”

Ullrich says they wanted to helpcreate a superior experience for pa-tients and families while facilitatingthe most innovative care in the world.“Dr. Stearns envisioned it. The pa-tient and families built it,” she says.

ONLY ON THE WEBWatch a video of the dedication event:bit.ly/2vshsDT

Take a video tour of the building:bit.ly/2MrSPxE

ON JUNE 8, 2018, approximately 200people, including family members,friends and business associates of SkipViragh; Johns Hopkins leadership;donors; art committee members;Under Armour representative StaceyUllrich; and breast and ovarian cancerprogram co-director Vered Stearnscelebrated the opening of the new SkipViragh Outpatient Cancer Building,home to the Under Armour BreastHealth Innovation Center.

When Stearns first met withUllrich, head of global philanthropy

for Under Armour, to discuss a KimmelCancer Center partnership with theathletic apparel company, she described a place that would pull together all breast health servicesunder one roof, creating a superiorexperience and delivering the mostinnovative care in the world.

This unique center delivers onthis vision and more. “When welearned of Skip Viragh’s gift, wesought to merge these two momentstogether and bring it to life,” says Ull-rich. “The Under Armour Breast

Health Innovation Center is builtwith the principle that wellness andillness can exist together. This floor—this entire building—will empowerpeople to continue to do it better, tobe survivors.”

The Under Armour BreastHealth Innovation Center, located onthe 10th floor of the Skip Viragh Out-patient Cancer Building, provides acomplete experience for breast can-cer patients and gynecologic cancerpatients, bringing together the bestclinical and supportive care in one location and accelerating research. It is also home to the Breast and Gy-necologic Cancer Multi-DisciplinaryClinic, where as many as 40 expertspartner with patients to developtreatment and supportive care plans.

[Celebration]

Skip Viragh Outpatient CancerBuilding, Under Armour BreastHealth Innovation Center Open

INNOVATIVECARE

cine and rehabilitation room providespatients the opportunity to consultwith a rehabilitative medicine expertto receive a plan to help reduce the

physical effects of treatmentand engage in physical and

occupational therapy.One-of-a-kind artworkfeatures patient illus-trations that turn chal-lenging diagnoses intobeautiful stories of

hope and inspiration. Photos of iconic Maryland

scenery, captured bySkyview Photos,—an

entrepreneurial group of BaltimoreCity middle schoolers in collabora-tion with Crossroads School, LivingClassrooms and Under Armour—alsobring life to the space.

For patients undergoing mas-tectomy, a nipple tattoo room bringsthe work of tattoo artist VinnieMyers—internationally recognized

THE NIPPLE TATTOO ROOM IS OPEN

Call 410-876-4638 to learn more about nipple tattooing .

Watch a webinar hosted by Vinnie and Anna Myers on Dec. 5th 2018.

bit.ly/JHUCancerSurvivorshipWebinars

Watch a video: Nipple Tattoos—A New Option for Breast Reconstruction.

bit.ly/2x9Apex

[

[Clockwise from top right: Attendees tour the physical medicine and rehabilitationroom; From left, Linda Jones, Stacey Ullrich, Bobby Jones, Vered Stearns; One-of-a-kind artwork features patients engaged in physical activities; Mark Viragh andStacey Ullrich

G 2018/2019 • BREAST MATTERS 54 BREAST MATTERS • 2018/2019

Gillian Lichota is the kind of womanwho leaves a lasting impression. It isn’tjust because she’s beautiful and fit, orthat she’s an adventurous research sci-entist who’s traveled the globe studyingthe effects of climate change and pro-moting conservation. Rather, it has todo with her incredible courage in theface of unthinkable challenges and herbold intent to inspire others.

During the early weeks of pregnancy, Gillian noticed the sudden appearance of a rather large lump on her breast. Initially, she wasn’talarmed. However, when she beganto feel a burning sensation and no-ticed an odd dimpling in that area,she could no longer ignore the lump.She shared her concerns with her gynecologist, who immediatelyscheduled a breast ultrasound to ex-amine the lump, followed by a biopsy.

The findings were shocking.Still in her first trimester of preg-nancy, Gillian was diagnosed withstage III breast cancer. The diagnosisseemed as untenable as her options.She could undergo surgery to removethis aggressive pregnancy-relatedbreast cancer, and risk losing herbaby in the process, or delay the sur-gery and take the chance that the can-cer would advance significantly.Gillian decided her unborn child de-served a healthy, cancer free motherand opted to have the surgery.

Wracked with fearand uncertaintyAs she was wheeled into surgery,Gillian anxiously wrestled with thegreatest fear and uncertainty of herlife. She thought to herself: “This seemslike an impossible mountain to climb.

It’s difficult to see the summit. How amI going to do this?” It was then that shemade a pact with herself to approachthis “impossible mountain” one step ata time. After completing treatment, shevowed, she would find the biggest, mostbeautiful mountain and climb it, justbecause she could! First, she wouldhave to endure all that stood betweenenvisioning the goal and achieving it.

Soon after surgery, son Kailenwas born, but Gillian’s experience as a new mother was hardly like that ofmost women. After undergoingchemotherapy while pregnant, and justfour weeks after delivering her son,Gillian underwent three more monthsof rigorous chemotherapy that left the

self-described adrenaline-junky-adventurer physically debilitated,emotionally and mentally.

“Women diagnosed with breastcancer under the age of 50 face aunique set of challenges. We mustalso consider issues of pregnancy, fer-tility, and family obligations thatcome with having young children.Their careers are often interrupted,adding financial strain to the emo-tional burden of the diagnosis itself.Few resources are geared towardhelping women like myself with theirtransitional reset and acceptance oftheir body,” says Gillian. “I could nothave endured the pregnancy, surger-ies, chemotherapy and first year ofmotherhood without the incrediblesupport of my husband, Boe, andamazing community of friends.”

Partnering with hermedical team ontreatment decisions Throughout her cancer odyssey she alsoleaned on her Kimmel Cancer Centerhealth care team, particularly her oncolo-gist Vered Stearns, M.D., whom Gilliansays “is very much about empowering herpatients with information and choice.”

“Dr. Stearns explained the latestresearch to me, but she left the finaldecisions up to me. She empoweredme to make the choices that felt rightfor me,” Gillian says.

Second chances and making everymoment countAfter completing her medical treat-ments and surgeries, Gillian worked toprove that wellness and illness can co-exist on a continuum and to become anexample for other young women af-fected by breast cancer. She trainedand conditioned her body, mind and

spirit to meet the goal she set out forherself before her first surgery. In thesummer of 2015, Gillian summitedMount Kilimanjaro in Tanzania, thehighest free-standing mountain in theworld, reaching approximately 5,895meters above sea level.

Despite fear and exhaustion—much like she faced when diagnosedwith breast cancer during her firsttrimester of pregnancy—Gillian againovercame the daunting task beforeher. She conquered the summit.“After six days of climbing for approx-imately nine hours a day, and underthe bright light of the full moon, wewere finally approaching the summit.As we climbed the glacier to reach thesummit, the sun was beginning to riseover Africa and everything was illu-minated. I was dizzy, completely ex-hausted and in pain, but the beauty ofit all was completely overwhelming,”she says. With a friend’s encourage-ment, and in spite of exhaustion, painand frostbitten fingers, Gillian madeit to the top. “I rose to the challenge and did it. Imade every moment count and nevergave up. I closed one chapter of mylife and opened another,” she says.

Overcoming fear and helping others Breast cancer is particularly aggressivein young women, and Gillian’s cancerwas no exception. In the spring of 2017,after five years in remission, the un-thinkable occurred. Her breast cancerreturned and, this time, it had spread.There was no cure. Still she was fueledby her passion for life and determinationto rise above her situation. Purpose be-came her antidepressant. She knew shewas in a unique position to help others.Gillian wanted a better experience foryoung women with breast cancer. Shewanted them to thrive in mind, body andspirit. “I decided to once again do thething I thought I could not do. I wantedto challenge old paradigms and changeperceptions of what it means to have—and to live with —breast cancer,” shesays. With this goal in mind, she startedthe iRise Above Foundation to directlybenefit the health and wellness ofwomen under age 50 who are diagnosedwith breast cancer.

Her foundation’s mission is tosurround young women with targeted,age-appropriate and connectedhealth and wellness resources to en-able them to rise above the residualeffects of breast cancer, complete alife-changing mind-body-spirit expe-dition, and enjoy long-term survival.

Gillian’s future plans includetagging humpback whales in Raro-tonga and leading other young breastcancer survivors on new adventures,including trekking through Nepal andthe Himalayas to reach Everest BaseCame, summitting Mount Kiliman-jaro followed by a safari, and hiking,biking, kayaking and ice-climbingfrom Chile to Argentina.

“There is a fear associated withfacing a new physical, mental andspiritual challenge, like climbing amountain or trekking through a re-mote place in a foreign country, thatis not unlike facing cancer,” she says.“Each woman has her own journey,and it is different. To step outside ofher comfort zone to do something likethis helps in healing and empowermentand offers confidence that she can risein the face of adversity.”iriseabovefoundation.org

GILLIAN’S STORYIncredible courage in the face of unthinkable challenges and a bold intent to inspire others.

“Each woman has her own journey, and it is different.”

[Feature]

6 BREAST MATTERS • 2018/2019 2018/2019 • BREAST MATTERS 7

OVER THE DECADE that Kimmel CancerCenter radiation oncologist Jean Wright,M.D., has been practicing, medicine hasbecome increasingly patient-centered.

“Therapies are being tailored tothe individual,” she says. “Treatmentprotocols have changed to make themmore convenient and tolerable for pa-tients, without sacrificing their efficacy.”

Wright, who heads the KimmelCancer Center’s breast radiation on-cology program and practices at itsSibley Memorial Hospital location,says that for select breast cancer pa-tients, her field is offering more andmore options to treat this diseaseover a shorter course, and with tech-niques and technology that can helpspare healthy tissue.

Wright’s radiation oncology colleague Sara Alcorn, M.D., M.P.H.,who practices on the Kimmel CancerCenter’s East Baltimore campus, saysradiation therapy for women in theearly stages of breast cancer wouldtraditionally entail daily treatmentsfor six weeks or more. Now, it is oftenpossible to cut that course in half.

“These shorter courses aremore convenient for patients,” Alcornsays. “It also lowers their cumulativeradiation dose, which can help lessenthe negative side effects that can ac-company radiation therapy.”

Wright says research has shownthat simple changes in patient posi-tion can also significantly reduce ra-diation exposure to healthy tissue.For patients with left-sided breastcancers who need radiation directedat the lymph nodes that cluster nearthe underarm, unnecessary exposureto the heart has long been a concern.

However, asking patients to take andhold a deep breath during treatmentpushes the heart back from the chestand downward, away from the radia-tion beam.

“We now use that techniquecommonly for the majority of our pa-tients with left-sided breast cancers,”Wright says.

The Johns Hopkins NationalProton Therapy Center, set to open inthe fall of 2019 at Sibley, provides moreopportunity to spare healthy tissue.Protons can be tailored so that theypenetrate only a selected depththrough tissue. Consequently, Wrightexplains, radiation stops at the tumor,preserving healthy, non-cancer tissuebeneath.

The most novel development inpatient-centered radiation therapy, saysAlcorn, is the potential to omit radiationentirely. For postmenopausal patientswith less aggressive, early stage breastcancers, the decision to administerradiation often falls into a gray zone.The Kimmel Cancer Center is currentlyparticipating in a study to determine

whether select patients can successfullyavoid radiation. Alcorn is also leadingefforts to design a tool to help patientsand their physicians decide togetherwhether to proceed with radiationtherapy based on preferencesconcerning side effects and values.

“By giving greater attention topatient preferences and quality of life,”she says, “we can tailor our approachin a way that reduces the burdens ofcancer therapy while still providingeffective care.”

“By giving greater attention to patient preferences and quality of life, we can tailor our approachin a way that reduces the bur-dens of cancer therapy while still providing effective care.”

TAILOREDTHERAPIESMaking RadiationTherapy More Patient-Centric

PROTONS ARE THE MOST NOVEL DEVELOPMENT IN PATIENT-CENTEREDRADIATION THERAPY, AND CAN BE TAILORED SO THAT THEY PENETRATEONLY A SELECTED DEPTH THROUGH TISSUE. CONSEQUENTLY, RADIATIONSTOPS AT THE TUMOR, PRESERVINGHEALTHY, NON-CANCER TISSUE BENEATH.

Sara Alcorn,M.D., M.P.H.

Jean Wright, M.D.

2018/2019 • BREAST MATTERS 98 BREAST MATTERS • 2018/2019

AFTER A RESIDENCY at Parkland Health & Hospital System,a fellowship at Johns Hopkins and a faculty position atNorthwestern University, Cesar Santa-Maria, M.D., recently

returned to Johns Hopkins. Santa-Maria is a clinician-scientist who splits his time between treating breast cancer patients andresearching new ways to fight the disease,working closely with laboratory scientists.This type of research is referred to as transla-tional medicine, as experts take problems

they see in the clinic back to the laboratory. Similarly, whatthey learn in the laboratory is then translated into noveltreatment strategies for patients.

“My desire to improve outcomes for patients withbreast cancer has motivated my entire academic career,”says Santa-Maria.

His main focus is immunotherapies, treatments thatharness the power of the immune system to fight cancers.More drugs are gaining Food and Drug Administration approval, and they have had dramatic results for some pa-tients, extending survival far beyond what’s been possiblewith other therapies. But, as single agents, they’ve shownonly a modest benefit for patients with breast cancer.

Santa-Maria’s research aims to change that by findingways to make breast cancers more immune-susceptible.He is leading a clinical trial to test combining immunotherapydrugs with other drugs known as Cyclin D Kinase inhibitors.These latter drugs are a standard of care for advancedbreast cancers, halting the cell cycle so that cancer cells can’treplicate. Recent research suggests that they also cause lo-calized inflammation in tumors. This inflammation is theresult of immune activity, and his trial will see if it canmake tumors more sensitive to immunotherapy drugs.

While at Northwestern, a different trial led by Santa-Maria showed that combining two immunotherapy drugsknown as checkpoint blockers—a PD-L1 inhibitor and aCTLA-4 inhibitor—benefited patients with triple-negativebreast cancers (those that tested negative for estrogen receptors, progesterone receptors and HER2). A new trialto confirm these results is planned. Much of the sciencebehind immune checkpoint blockers—drugs that thwartthe cancer cells’ ability to hide from the immune system—was developed at the Kimmel Cancer Center’s Bloomberg~Kimmel Institute for Cancer Immunotherapy.

“By finding ways to make breast cancers more vulnerable to immunotherapies,” he says, “we’re hoping to attack this disease in a whole new way and ultimatelyimprove outcomes for patients.”

HARNESSING THE POWER Bringing the Promise of Immunotherapy to Breast Cancer

SUPPORTING PATIENTSON THE BREAST CANCERJOURNEYAFTER MEDICAL school in Irelandand an oncology fellowship in 1995 at

Johns Hopkins, RimaCouzi, M.D., knew thatshe wanted to focus onbreast cancer. She wasattracted to the idea ofhelping other womenthrough their cancer

journeys. After her two sisters developedbreast cancer, Couzi had a renewedfocus on leading the fight against thisdisease.

“It’s a personal motivator for me to do the best I can for everypatient in front of me,” she says.

Couzi returns to the KimmelCancer Center in January 2019 withan impressive depth of experiencethat includes treating thousands ofbreast cancer patients over the lasttwo decades at the University ofMaryland St. Joseph Medical Group.Her goal is to use the knowledge shegained to develop customized treat-ment plans for breast cancer patients.

She will be based primarily atthe Kimmel Cancer Center’s Green-spring Station location, where herpractice will focus on evidence-basedcare and access to clinical trials.

Beyond caring for patients withacute disease, Couzi notes that muchof her work has focused on the issuesthat arise with survivorship. Thesemay include residual side effects fromtreatment, worries about the risk ofrecurrence, side effects of hormonaltherapy and other ongoing issues.

“Because the prognosis of mostbreast cancers is quite good, we havea lot more survivors in breast cancercompared to many other types of can-cer,” she says. “Our clinics rapidly fillwith survivors. Every breast cancerpatient has specific medical issues,along with unique concerns and emotions. My job as a clinical oncolo-gist is to support my patients duringthis complex journey.”

Tracie Cline, 25, spent her whole life ina small town in Pennsylvania, but theenergetic young yoga instructor soughta new adventure. She’d always wantedto live at the beach and was preparingto move to Charleston, South Carolina,with her trusty dog Mia, an Australianshepherd/collie mix, when she found alump in her breast.

On the first day of spring in 2018,Tracie was diagnosed with HER2-posi-tive breast cancer. Confronting breastcancer upended her plans, at least tem-porarily. It also frightened her. She knewwhat would calm her anxiety and fearswhile receiving treatment, but shewasn’t sure if she’d be able to use thatsource of support in a hospital setting.

“I told my nurse navigator,Catherine Klein, ‘I don’t want to do thisif I can’t have Mia with me,’” recallsTracie. “She makes me more comfort-able and at ease when I’m scared.” Inturn, Klein, whose role as a breast can-cer nurse navigator is to help breastcancer patients through their treatmentand recovery journey, assisted withinitiating the process so that Mia wasallowed to accompany Tracie to herappointments as an emotional supportanimal (ESA).

ESAs are pets that provide comfort to their owners duringstressful situations. In a medicalsetting, they are considered part ofthe treatment program as theyminimize patients’ negativeemotional symptoms, according tothe National Service Animal Registry.Unlike service animals, ESAs don’trequire specific training. They simplymust be manageable in public.

A 2015 study in the Journal ofCommunity and Supportive Oncologywas the first to document the improvedemotional well-being of cancer patientsusing animal-assisted therapy.

“She steals the show,” says Tracie.Everyone’s like, ‘Hi Mia.’ She just lightsup everyone’s faces.”

Cline is thankful for her healthcare team, including her nurse navi-gator, surgeon Mehran Habibi andoncologist Roisin Connolly, for mak-ing it possible to have Mia be a part ofher treatment process. Subsequently, Tracie is considering “paying for-ward” the goodwill by seeing if Miacould be an ESA for cancer patients ather local hospital in Pennsylvania.

A PATIENT’S BEST FRIEND

{ Mia }

{ Tracie}

Neha Mangini, Pharm.D, the only pharmacist at JohnsHopkins who specializes in treating breast cancer patients,explains her integral role on the care team. Mangini serves as an important resource for prescribing physicians and patients alike.

What role do pharmacists play in caring for patients with breast cancer?In the last five years, there have been several new oral medi-cines approved for breast cancer that target specific charac-teristics of cancer cells. These oral therapies offer theconvenience of more time at home and fewer visits to the

oncologist’s office or to the infu-sion center. However, they doplace greater responsibility on thepatient and the caregivers to knowhow to properly take the medicine,track the on-days and off-days of acycle, and what side effects arecommon and how to manage themand which ones require a phonecall to the medical team. There is

also a lot of care coordination, as these medications are oftenmailed from specialty pharmacies to the patient’s home. Ihelp educate patients on how to take these medicines andsafely handle and store them at home. I try to empower pa-tients on ways to prevent common side effects. Behind thescenes, I’m making sure the medicine is dosed properly basedon their kidney and liver function, identifying if there are anyserious drug-drug interactions, getting prior authorizationapproved by the insurance and helping order the appropriatelabs for monitoring. When patients first start on a new medi-cine, I provide teaching in person or over the phone. I alsocall them within a week of starting to make sure they’ve re-ceived the medicine and that they’ve gotten off to a goodstart. After that, I check in at least once a month so that theyhave the support they need.

I also serve as a resource to the physicians, nurse practitionersand nurses on the cancer care team by helping answer druginformation questions—for example, how to dose chemother-apy for a patient on dialysis or what chemotherapy and sup-portive care medicines are safe during pregnancy.

What special challenges do these patients have from a pharmaceutical perspective?I’ve noticed that many patients with cancer take complemen-tary medicines, herbal supplements or vitamins. I lookthrough the available data to make sure everything they takeis safe and won’t conflict with their prescribed cancer medi-cines. I make sure their supplements do not have phytoestro-gens—plant based estrogens—as they can encourage sometypes of breast cancer to grow. Sometimes patients may stoptaking medicines because of side effects without letting theircancer care team know. I work with patients to make surethey remember to take their cancer medicine every day.

In what other ways do you helppatients manage their disease?The new oral targeted therapies can be extremely expensive,up to $10,000 per month without insurance. Many of my pa-tients are insured through Medicare, which has a coveragegap, also known as the “doughnut hole,” where they have topay $5,000 out-of-pocket every year. Patients withoutMedicare can also have high copayments. I work closely withour patient assistance program specialists to utilize all avail-able financial resources to help our patients afford their can-cer medicines. These include one-time free trial vouchers,copay cards, nonprofit grants, and free medicine programsfrom the manufacturer. In 2018, we helped 248 breast can-cer patients by obtaining 91 copay cards, 73 nonprofit grants,and 84 free medicine approvals from the manufacturer.

What advances do you see on the horizon for breast cancerpharmaceuticals?One of the most exciting developments for cancer in generalis the use of immunotherapies, medicines that harness theimmune system to fight disease. Some seem promising forcertain types of breast cancer, such as triple negative breastcancer. I am also excited to see clinical trials of oral targetedtherapies that are currently FDA approved for advancedbreast cancer being studied for earlier stages. The goal iskeeping cancers from coming back so that people will livelonger with cancer and so that more cancers will be cured.

[Ask the Expert]NEHA MANGINI

2018/2019 • BREAST MATTERS 1110 BREAST MATTERS • 2018/2019

A SINGLE MALIGNANT cell becomestwo, then four, then eight. As a tumorgrows, these multiplying cells eventu-ally put a strain on local resources and

grow away from bloodvessels, starving themof oxygen. But whileoxygen deprivationmight be a death sentence for normalcells, it can be the

opposite for cancer. Studies have shownthat a lack of oxygen causes cells to stabilize the production of proteinscalled hypoxia-inducible factors (HIFs),which affect the activity of hundreds ofgenes involved in chemotherapy resist-ance and metastasis—the migration ofcancer cells that is responsible for mostcancer deaths.

Although some drugs directedtoward HIFs have been tested in clinical trials, they haven’t been verysuccessful at treating metastatic can-cers, says breast cancer researcherDaniele Gilkes, Ph.D. One reason forthis failure, she adds, is that relativelylittle is known about exactly whathappens to cells that produce HIFs.

“If we could get a better handleon the timeline of events after cellsare deprived of oxygen,” she says, “wemight find subpopulations of cancerpatients for whom these drugs couldbe helpful.”

Funded by a $150,000 grantfrom the Emerson Collective CancerResearch Fund, Gilkes and her col-leagues are using a novel method tobetter understand the superpowersthat malignant cells develop oncethey’re oxygen-starved.

She is using an animal breastcancer model that her lab developedthat shows which cancer cells are

deprived of oxygen. In this mousemodel, breast cancer cells glow redwhen they’re exposed to light. Butonce they become oxygen deprived,they glow green.

By harvesting these cells, bothwithin the tumor and after theymetastasize to locations such as thelungs, liver, bone and brain, the re-searchers can use a technique calledflow cytometry to sort cells by theircolor and analyze which genes mayhave developed mutations betweenthe two groups and which have differ-ences in activity that may enhancetheir ability to metastasize.

SORT, COLOR, ANALYZEA Better Understanding of Metastasis

“If we could get a better handle onthe timeline of events after cells aredeprived of oxygen, we might findsubpopulations of cancer patients forwhom these drugs could be helpful.”

This technique will help re-searchers figure out which cells areoxygen-deprived among the diversecellular mix of tumors. It will alsohelp them establish when geneticchanges that affect cellular behaviortake place. This knowledge could help answer questions, such as dospreading cancer cells maintain thesechanges or do the cells “reset” whenthey reach their new environment,says Gilkes.

This fundamental knowledgecould lead to better ways to fight cancers, she adds. As part of this lineof research, she and her colleaguesplan to test whether oxygen depriva-tion is what triggers resistance tochemotherapies in triple-negativecancer, a type of breast cancer thatoften becomes untreatable with con-ventional medicines, leading to a poorprognosis. They also plan to study iftargeting the hypoxic cells—essentiallyusing a genetic modification to kill thembefore they migrate—can prevent re-duced sensitivity to chemotherapies.

“We need a different strategy totreat metastatic cancers,” Gilkes says.“Right now there is no cure. Our goalis to change that.”

RESEARCHERS USE ATECHNIQUE CALLEDFLOW CYTOMETRY TOSORT CELLS BY THEIRCOLOR AND ANALYZEWHICH GENES MAY HAVEDEVELOPED MUTATIONS.

2018/2019 • BREAST MATTERS 1312 BREAST MATTERS • 2018/2019

Birdland Hero Breast cancer expert and preventionpioneer John Fetting, M.D., was hon-ored by the Baltimore Orioles as a Bird-land Community Hero on Mother’sDay at Oriole Park at Camden Yards.The honor recognizes community he-roes who inspire others through char-ity and community service. Fetting wasnominated by former patient andbreast cancer survivor Leslie Ries andsurvivor and patient navigator JillMull. After Leslie was diagnosed withbreast cancer, she and her husbandTom established The John FettingFund for Breast Cancer Preventionat the Johns Hopkins Kimmel CancerCenter to help support bench to bed-side research that will make breastcancer prevention a reality. “Recogni-tion of Dr. Fetting is both an honor forhis own efforts and also for the manypeople who work tirelessly in Balti-more and across the country to care forpeople with breast cancer and to con-duct breast cancer research, ” Ries says.

Breast cancer expert Roisin Connolly,M.B.B.Ch., was promoted to UC

Associate Professor.Connolly is leadinglarge national clinicaltrials testing epige-netic therapies— treatments that targetchemical alterations

to genes that can support cancergrowth—in combination with immunetherapies and hormone therapies.

Vered Stearns, M.D., co-director of the Breast and Ovarian Cancer Pro-

gram, was named tothe Forbes list of thecountry’s top breastcancer oncologists.

Antonio Wolff, M.D., was included onThomson Reuters’ 2017 list of the most

highly cited re-searchers in the sci-ences and socialsciences in the world.Wolff was also namedone of the AmericanSociety of Clinical On-

cology’s Advocacy Champions for edu-cating lawmakers on important cancerpolicies that help ensure high-qualitycancer care in the U.S. remains avail-able to all.

Antonio Wolff, M.D., and Susan Harvey, M.D.,were elected to theMiller Coulsen Academy of ClinicalExcellence at Johns Hopkins, which

recognizes and promotes excellence inpatient care.

EVENTROUNDUPUpcoming All events are FREE and open to allbreast cancer survivors, thrivers andcaregivers unless otherwise noted.

Integrative MedicineFree monthly integrative medicine lunchworkshops on rotating topics for patientsand their caregivers. Previous topics in-cluded mindfulness, meditation and Reiki.Upcoming sessions include acupuncture,various art therapies and herbs. For moreinformation or to register, contactElissa Bantug at ebantug1 @jhmi.edu

Caregiver WorkshopNov. 3, 2018, 9 a.m.–12 p.m.A workshop to address the roles ofcaregiving (nurse, chef, counselor, taxidriver, financial coordinator, secre-tary), how to build a team, coping tech-niques, communicating with yourmedical team, and internal and com-munity resources. For more informa-tion, contact Elizabeth Saylor atesaylor4@jhmi.edu.NOTE—this is open to caregivers only.

Support GroupsMonthly support groups: 6-7:30 p.m.First Monday of the month—YoungWomen with Early-Stage Breast CancerThird Monday of the month—Metastatic Breast CancerGreenspring Station. Topics varymonthly. To find out more, contactElizabeth Saylor at esaylor4@jhmi.edu.

Walk and TalkThird Friday of each month, 9-10 a.m.Join our breast cancer navigators as we walk through the mall and get someexercise! Every month features a breastcancer “hot topic” and related resources.Meet inside Towson Town Center at thetables outside of Nordstrom Rack.

The program is free, but registration is required. Contact Jill Mull atjmull1@jhmi.edu to reserve a spot.

WebinarsNipple Tattooing hosted by Vinnieand Anna Myers—Dec. 5, 2018bit.ly/JHUCancerSurvivorshipWebinars

Pelvic floor, sexual health and breastcancer hosted byMary Austin Watch previous webinars:bit.ly/2LKVH7C.

Survivorship Day2019 Breast Cancer Survivorship Day More information to come athttp://bit.ly/2zzcUhl

Prior Events RecapSurvivorship DayAnnual Breast Cancer SurvivorshipSymposium: Open to all breast cancerpatients, survivors, families andcaregivers, sessions included: How toMaintain Overall Health and WellnessAfter Treatment; Side Effects fromCare; Spirituality; Fear of Recurrence; Follow-up Guidelines; What’s New inResearch; Long-Term Survivorship;Sexuality and Intimacy; Nutrition; Exercise; Integrative Medicine;Fertility; Breast Reconstruction; Livingwith Metastatic Cancer; Caring for theCaregiver and Helping FamiliesThrough This Difficult Time.

WE’RE GROWING!The Kimmel Cancer Center at Greenspring Station will move tothe first floor of Pavilion III and is scheduled to open in April 2019.

HONORS AND AWARDSSurvivorship expert Don Dizon, M.D.,was keynote speaker. Johns Hopkinsmedical and nursing studentssupervised the kids program, providinga variety of fun activities.

Bowling FiestaPatients, families and friends came together for unlimited bowling and delicious Mexican themed food atStoneleigh Bowling Lanes.

Running on Empty:Fed Up with Fatigue—Living Beyond Breast CancerYoung Women’s Initiative and Johns Hopkins Medicine collaboratedon a program presented by Lillie D.Shockney, M.A.S., discussing practicaland medical methods to ease cancer-related fatigue. Watch the presentation:bit.ly/2LLMdZK.

Survivor Soul StrollPink was everywhere on June 9, 2018,as 850 participants declared their commitment to battling breast cancerduring the second successful year ofthe annual Radio One Baltimore Sur-vivor Soul Stroll, benefiting the JohnFetting Fund for Breast Cancer Preven-tion at the Johns Hopkins KimmelCancer Center. The three-mile charitywalk was held at Druid Hill Park.

EVERY DRINK MAY matter when it comes to breast cancer. Although there is considerable evidence linking alcohol consumption with breast cancer, most women are unaware,and research so far has not yet revealed how it causes breastcancer or who may be most at risk. With support from the JohnFetting Fund for Breast Cancer Prevention, epigenetics ex-pert and breast cancer survivor Cynthia Zahnow,Ph.D., hopesto shed new light and explore what role epigenetics may play.

Epigenetics is the study of chemical alterations thathelp control gene expression and, as a re-sult, the behavior of cells. Zahnow andher Kimmel Cancer Center colleaguesare among the leaders in cancer epige-netics, deciphering how these chemicalalterations can turn genes on and off andcontribute to cancer development.

Although alcohol consumption increases breast cancer risk for women of all ages, Zahnow says youngerwomen may be most vulnerable because breast tissue isthe most sensitive to environmental exposures from thestart of menstruation until first pregnancy. She says it’s important to point out that it’s alcohol itself, not the typeof alcoholic drink (beer, wine, whiskey, etc.) that is associ-ated with breast cancer risk.

“It’s quite clear that the more alcohol a woman drinksand the younger she drinks contributes to a greater risk ofbreast cancer, but little is known about the underlyingmechanism,” she says. “We want to understand specificallywhat amount of alcohol consumption increases risk. Is it

one drink a week, or are other epigenetic or mutagenic hitsrequired in addition to this to confer risk?”

As a member of what is considered among the bestepigenetic programs in the world,Zahnow hopes this research will provide important information thatcould modify a person’s drinking be-havior to help lower the risk of breastcancer. She wants to determine howmuch alcohol, if any, is safe for women.“This is an easily modifiable behavior,” she says, and shewonders, “As a breast cancer survivor, should I be drinkingat all? And, what about my daughter who is a senior in col-lege? I also want to know if it’s safe for her to drink, and howmuch alcohol is too much.”

Zahnow and graduate student Cassie Holbert willstudy normal breast cells to see how their behaviorchanges when exposed to alcohol. For example, does alco-hol cause breast cells to become more invasive, growinginto ducts where they should not be? She will also examinebreast cancer cells obtained from women who drink alco-hol to look for similarities in epigenetic changes. “Ourlong-term goal is to come up with an alcohol induced epi-genetic profile that could help to identify women who maybe most at risk for developing breast cancer,” says Zahnow.

Zahnow hopes her research will provide importantinformation women can use to make informed decisionsthat could reduce their breast cancer risk.

Understanding Alcohol’s Contributionto Breast Cancer Risk

CHEMICAL ALTERATIONS

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IT'S QUITE CLEAR THAT THEMORE ALCOHOL A WOMANDRINKS AND THE YOUNGERSHE DRINKS CONTRIBUTESTO GREATER RISK OF BREASTCANCER, BUT LITTLE IS KNOWNABOUT THE UNDERLYINGMECHANISM.

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