[On-screen text: 
Ohio State Health & Discovery Health Talks]
Gail Hogan: Welcome to Health Talks. I'm Gail Hogan, and today we're discussing what we now know in breast cancer research. Dr. Bhuvana Ramaswamy is here to give us the latest updates. Dr. Ramaswamy, when did you start working with breast cancer patients?
Bhuvana Ramaswamy, MD: So I came to Ohio State to be a breast medical oncology fellow in 2002. So then that was about a couple of years. Then I did a year in the lab and then one year you had to kind of do all other oncology work and then I became an attending in breast medical oncology in 2006. But I would really say from 2002 is what I really started to work and it inspired me. I mean, the patients inspired me to say “This is my calling,” and I got to be here and I've never looked back.
Gail Hogan: You also do research, so can you tell me a little bit about what took you down that path and the path that you're focusing on?
Bhuvana Ramaswamy, MD: It's a great question because to be honest with you, when I came in and joined as a fellow, I hadn't done a lot of research. I got my medical degree in India and then I did some further work called MRCP in England, but they were all very clinical, so I hadn't done much research. So it was definitely a new thing for me. But even as I started to get into breast cancer, I realized everything that they were doing there at that time, everything was a little new. We were still kind of coming into newer drugs and I realized none of them is possible without those clinical trials. I mean, not a single drug is going to be approved without those clinical trials. So I kind of really leaned in on understanding how important is clinical research. But as I got to understand that, I realized if I don't understand the language of how these markers, these molecular targets are even identified in the lab, I would never really, I need the deeper understanding to be a better physician and better oncologist.
So that's when, for the first time in my life, I went into the research lab for two years. I'm pipetting for the first time after a long, long years ago from school. So it was tough. It was tough to be in a lab and do some really basic research, but it really helped me and I enjoyed it in a way that you are able to answer questions that comes up and also understand how hard, I mean it's just so you can work for a week and then nothing works out in the experiment. So I finished that and then of course I started working initially mainly in clinical research as an attending. So I was kind of working in those pathways. And then I became a medical director of the clinical trials office along with another hematologist. And so then that was another interesting administrative work and also to improve clinical research.
That's when I started to collaborate with another basic researcher in breast cancer and started to kind of again, dig deep. So now I have my own lab and I have NIH grants to support that. And what I'm looking at is kind of interesting to see why lack of breastfeeding or abrupt stopping in short-term breastfeeding increase the risk of an aggressive type of breast cancer as opposed to a prolonged weaning at least four to six months, a total of 12 months with how many of children you have reduces your risk of breast cancer. So that data is very, I mean there's just so many papers on that, but what exactly happens because your breast undergoes many changes, puberty changes, and then in pregnancy changes, then it's ready for being where it can do lactation, but then at the end of the day, it undergoes involution, right?
It goes back to the pre-pregnant state. How is it different between abrupt involution and a gradual involution? And that's what we are studying with animal models right now. It's a very interesting project because A one, we understand the molecular link and it can improve then our, not only our messaging to our women and also messaging to the government. It gives them opportunity for women to stay home and breastfeed. It's going to be important or making sure there is enough lactation space in every place and give time for people to women to be able to do that because they may have to work. So it doesn't mean everybody has to breastfeed, but maybe we can do better, but also understand other kind of interventions that we can do for those who cannot breastfeed. So that is one thing that I am really, really passionate about and I'm really also passionate about because when you look at it from the health equity perspective, African-American women have 40% higher chance of dying from breast cancer.
Part of the reason there are many reasons for this. Part of the reason is because they have a higher chance of getting this triple negative breast cancer, which are a little bit more aggressive. I mean very much more aggressive. And the connection is between the lack of breastfeeding and this type of breast cancer and the prevalence of breastfeeding is much lower among African-American women and that we won't go deep into why or why not, but we can address this. And so there are many facets to this and I'm very excited to work on this and because prevention, it's the best thing that we can do. And I want to work further on this and we do a couple of other more drug resistance and invasive lobel cancer studies and things like that in my lab.
Gail Hogan: What have been some of the greatest discoveries? I know that we have come a long way in diagnosing and prevention and curing in many cases.
Bhuvana Ramaswamy, MD: Absolutely.
Gail Hogan: What are some of those greatest discoveries?
Bhuvana Ramaswamy, MD: Absolutely. I think we are curing more. There's no doubt about that. Patients who come in with early breast cancer, the number of people who are being cured, particularly if they come early enough, but even if they are a little bit later, the percentage before to after has changed. That's because we are able to do better surgeries and sometimes less surgeries, less amount of surgery. And we have fantastic radiation strategies and methodologies to be able to make sure there's no local recurrence because local recurrence increases the risk of distant recurrence and death. So we are able to do that better. But I think a lot of it is understanding the biology of the cancer and we are able to target what makes the cancer grow, like what feeds the cancer. And we are targeting with extraordinary amount of fantastic medications. And when I say medications, canceled drugs, that has definitely improved the outcomes of the patient.
So that's a big part of what's really changed. And the other thing that I would say has changed is as well, really understanding their nitty gritty stuff that is the gene sequencing that we are able to do now because of course we now know our genome and everything is set up, so we are able to actually do it much easier. We were able to do it for a long time, but it was very difficult. But now much easier to do these gene sequencing and not only just from always having to do bio, you can just do liquid biopsies and remove just the circulating tumor. DNA can even think about how fascinating that is. And you can do that so you can actually see how your cancer evolves over time. And I think this understanding of not just cancer therapies and biology, but also understanding how the patients are having side effects from the treatment and how can we address that instead of saying Barrett, it just comes with it because we can cure you. We don't do that anymore. We really listen to the patients. I think patients' advocacy has increased as well. And we really believe in what's called a shared decision making. We didn't do that a lot before. So I think there's a lot of that from all sites, an improvement in care and extraordinary breakthroughs that has come through medications, cancer, drugs, as well as through our understanding of the biology.
Gail Hogan: So what would you say has been the biggest breakthrough in say the last three to five years?
Bhuvana Ramaswamy, MD: In the last three to five years? Yeah, we've had I think three or four new drugs that got approved, which is amazing, which can even, it's unbelievable. Just in the last three to five years we are able to use many new kind of drug, which is just so fascinating. When I talk to my patients, I call them smart bombs because what's on the surface of your cancer cells? So we develop an antibody to that, which we are able to do it so fascinatingly, and then you have a linker that attaches that to a chemotherapy. So it goes inside. So that molecule attaches the antibody here, it goes inside, births open, and then the chemotherapy comes up. That antibody drug conjugate concept has really revolutionized many cancers. But the other thing that we have to really not miss, so I'd be very wrong in doing that, would be the immunotherapy part of it, that now immuno-oncology is like a separate strategy of treatment for cancers and so many are doing, can't even believe what is done to lung cancers, melanomas, and many hematological cancers, but now it's coming to breast cancer. So to understand even better on this and get more drugs on the immuno-oncology and understand how our own innate immunity can be adjusted to fight your cancer. These are just fascinating things. Fascinating things we are able to
Gail Hogan: Do you see new breakthroughs right around the corner? 
Bhuvana Ramaswamy, MD: Absolutely. I think we'll see a lot of new breakthroughs because we are able to understand our immunology better, how our host kind of factors affect the response to therapy, and they're able to make all these molecules that they're able to attach two or three antibodies together. And so this ability to create new drugs after you understand what's the target, I think we're just going to see new very great breakthroughs coming around and I think it's going to continue to come around. So there's no end to this. We got to go to the finish line, which means cure for all. But more importantly also, it'll be great at some point to say that we can cure metastatic disease. It is a tough thing because you have circulating tumor cells, you have disseminated tumor cells, and they are all so different within that same patient. But my sincere hope is that we can say we can even cure them.
Gail Hogan: And that's why research is so critical. 
Bhuvana Ramaswamy, MD: Exactly. Very critical. It cannot stop. And with us being so advanced in ability to really understand more, anything you take microscope, you take ability for us to do stuff with the tumor tissue, I mean it's endless. So if we have all those tools, we have to understand it better, so understand cancer better the disease is better, and then find a way to fight it. So it's not going to stop.
Gail Hogan: You explained how research has been beneficial in the physical part of treating a patient, but how has research come around to treat the other part of the patient, meaning the mental health of the patient, the emotional state of the patient.
Bhuvana Ramaswamy, MD: Anything that we do in research has to start first with acknowledging that there is a problem. And once we know that that's a problem that is going to actually interfere with the way the patient is going to accept the treatments and survive the treatments, then we start to really look deeply into that. So I think we are definitely on that path. I think we have started to understand that patient's performance status in the physical sense, but also patients emotional status is going to be very important on how they're going to adjust to the therapies and live well sometimes with the cancer or even if you're a cancer survivor. So I think it is improving because many things we are doing better. We are first of all using patients report our outcomes into our, most of the studies now are including patient reported outcomes. That means it's not just you saying they had tingling numbness in their hands and feet, it's also what they are saying.
So it'll actually go into that as a separate thing, which is excellent. So we are starting to understand really from their voice what's coming in patient advocacy in all these areas. Survivorship living well with advanced breast cancer for the matter. We have a clinic like that to kind of educate those patients who have cancer and have to learn to live with it, how to adjust to various aspects of it. So I think we are getting better. We are getting better certainly in addressing those side effects and how we can manage that. I think we are getting better to understand dose reductions and how that can impact their symptoms and may not impact the cancer outcomes. So we are really getting judicious about that and doing a little bit more of that than we did before. And also addressing the young women with breast cancer because that is unfortunately also increasing and addressing if they want to have children in the future, how do you address that and whether you need to freeze their whelm or do they want to have an embryo frozen?
So we are really thinking on those lines. How do we avoid them losing their hair? We have scalp cooling coming into play and insurance is not approving it yet, but we'll get there. Everything starts with a fight, but we are able to keep their hair for not saying for everybody, it's for a few people, but it's a start. So we are addressing this. We addressing their side effects, including sexual symptoms, which we used to just ignore because everybody's kind of don't want to talk about it. But now we tell the patients, no, you can't. And we make sure we ask those questions. And I think that all of this, these are called non-therapeutic interventional trials. How does acupuncture help with aches and pains and hot flashes? So all this is increasing tremendously. So I think we are on the right path. There's more to do, but we are doing much better than we did before.
Gail Hogan: You have research on drug resistance? 
Bhuvana Ramaswamy, MD: Yes. 
Gail Hogan: What does that mean and what kind of research are you doing?
Bhuvana Ramaswamy, MD: So we could cure all cancers all the time if we are able to understand this really, right? Because we have great drugs, there's no question about it. But what happens for those unfortunate few is that then cancer doesn't respond to this fantastic drug. And so they, okay, you block this path for me from growing, I'm going to find another door and escape that and grow. So one of the things these cancer cells have in their DNA is that they really want to survive. So it's almost like a traffic thing. So you block one, there's a diversion and they'll grow that. Right? So you're
Gail Hogan: Trying to outsmart it.
Bhuvana Ramaswamy, MD: We have to outsmart it. Exactly. And the issue is unfortunately why we are definitely doing better because we know to outsmart some of those. So we give two drugs together. I know this is the way you'll go. If I block this, I'm going to give this together. So we do that. But then unfortunately some cancer cells are so smart they'll find a third pathway. But that's what we are learning. We're learning, we're getting there. Everything's a step-by-step process, but that is the resistance part where it's the conventional therapies or therapies that work, even though they have those targets don't work. So we work in the lab to use those cell lines to understand why we isolate those cells that didn't respond to that conventional therapy and start to understand their genes and find an alternate therapy that could work on those cells and then administer that use animal work and all of that to understand this better. So that's what drug resistance is, is one of the most important things to address if you want to cure all cancers.
Gail Hogan: So why should someone come to a comprehensive cancer center like the James? 
Bhuvana Ramaswamy, MD: Great question. And I think it's a very important question. I certainly am not saying everybody who gets diagnosed with cancer have to travel far and come to a comprehensive cancer center. And I think community oncologists provide an extraordinary service to our patients and extraordinary care to our patients. So I'm not saying that, but I do think everybody should make an attempt to at least have a visit with the comprehensive cancer Center. Why is that? Because you have expertise or experts or doctors who have just working in your type of cancer. So most of us are only working. I only see breast cancer. I've only seen breast cancer for the last whatever years. So it does give you that expertise. Your cancer surgeons have only doing surgery in one, maybe two cancers at best. So there is that expertise that comes. In addition, we have the cutting edge clinical trials, which is so important.
Every pill that you're taking right now as a cancer person living with cancer or a person with cancer who had had cancer, it was on clinical trials before and some patients were willing to go on that study that now it was approved and you're able to take it. And so everything advances are understanding. So it's important to come in and see whether you have a clinical trial that is appropriate for your treatment. The other thing that we all do is we think clinical trials are only when there's no other option, and that is very wrong. That's a very wrong concept. Many of us, many people have clinical trials for anything. The reason your treatment after cancer is diagnosed is changing and it's changing every time to better outcomes is because we have trials there when you're initially diagnosed. So it's important that you come and have a discussion with the cancer experts to make sure you are on the right path. So I would say at least make an attempt to come in and visit. It may not be worth it to travel all the way to get the same treatment, and you are probably getting a great treatment there and that's fine. But I think it's important for them because of these cutting edge and the expertise and the clinical trials, they have to come here and get at least an opinion. 
Gail Hogan: That was my next question is how would you explain this to someone who's ambivalent in saying, I'm going to stay in my small town and I'm going to be fine. What would you say to convince them to come to the James?
Bhuvana Ramaswamy, MD: So generally when they come to see us, I don't tell them that they have to move here. Very rarely I say that. So I tell them that you are getting these, but I have a clinical trial that is much better for you, much better for this. Or as you're progressing, it's much better for you. So if I were you, I would not worry about the transportation time, but if I'm going to recommend them to get a standard of care therapy and they're really happy with their doctors and the care and the nurses, I don't convince them to come back. But I think if their treatment is going to be better here, treatment option is going to be better here. I do tell them that's so important for them, and I talk to them quite a lot. But at the same time, we all have to understand one thing that's very, very critical to our patients or anybody with cancer or chronic illnesses, financial toxicity and traveling far and having someone to drive you and feeling that pressure that you're putting on others.
These are all real factors. So I really tell them to come here only if they're going to get a different treatment or they feel more confident to be here, then it's very easy. Of course they're telling you, no, no, no, I don't want to go back and I stay with you. Yeah, of course. I mean, we always do the best what they want, but I don't really make sure What I really am appealing to patients with cancer is that somehow make an effort. I'm not make an effort to go to a comprehensive cancer center to get an opinion, at least at points of progression or at the initial diagnosis that you know are on the right path. That is something that I really want. Whether you want to stay there or not, depends on so many factors, and that is a different matter. So
Gail Hogan: We're going to switch gears a bit because you are a breast cancer oncologist and now you're having your own personal journey with breast cancer. How did you discover that you had cancer? Breast cancer?
Bhuvana Ramaswamy, MD: Yeah. So it was just a Thursday morning, which was my really busy clinic days. And in the shower I just felt a lump in my right breast, which I've never really felt before. It was pretty obvious it was sitting right up on the top. And so even as I felt it, I knew that what it's going to be because it was so distinct. But I still had to finish my clinic on Thursday and then Friday, I think Thursday morning itself actually, I asked one of my colleagues, senior colleagues to examine me and she used a bad word. I shouldn’t say examined me. So I knew that it's not a good thing, but I had my biopsy the very next day. So this is, you're talking in 2016, that's when we discovered in April that I had a type of breast cancer that is kind of extremely rare that I wrote. We wrote a case report of my cancer. It is triple negative, which I think people may understand that, that it's not dependent on estrogen, progesterone or HER two, but the histologically that is under the microscope is a very rare tumor called neuroendocrine cancer of the breast. It doesn't usually happen in the breast, so it's very rarely a few case reports are there.
Gail Hogan: What's your journey been like?
Bhuvana Ramaswamy, MD: It's been interesting and there are so many things you learn in this journey that is, although you've done this for years, I've done this for years and I love doing this job that I do as an oncologist. And I think that I take a lot of time to spend time and understand my patients and provide the comfort because even if you can't cure, I think that's the least you can provide. But really being in their shoes has opened up many things that I really thought would be easier is harder. So even as simple as constipation, which I used to think, oh, it's just constipation, but my God, it literally stops everything. So it is hard, and that is the physical aspect of it, but emotionally as well to focus on the future and being positive is a very important thing. And the other thing has also been that I understood that how much ever people around you are trying to help you, that is your family, your work family, and all the other friends that you have, it is extremely isolating because at the end of the day, you are losing the hair and you are got to come and get the chemotherapy.
You know that you are still facing mortality. You have to decide how you want to live and how do you want to live your days and could be years, multiple, multiple years. And staying positive is very key. 
Gail Hogan: So you think you did take a little different approach after you were diagnosed?
Bhuvana Ramaswamy, MD: Absolutely, Gail. I think not the treatment because we always do the best that we can with the treatments and nothing has changed. But I think the way I provide support to my patients, both from even them saying, no, I don't want to do this anymore. I don't want to have my last chemo. It was very difficult to understand before, but I could understand their symptoms and the gravity of the symptoms on them so much better than I did before. And then of course the gravity of the diagnosis emotionally. And I think when I use the word, I know how isolating, even though your husband's sitting here is so loving, how isolating it is for you, and you could see them brightening up as though finally somebody understood. So I do think I've taken a slightly different approach, but I do want to say there's something that I feel happy about and I am very keen on.
It's so funny that I can actually just kind of compartmentalize my problems. So when I go and see the patient, I forget that I have the same problems sometimes exactly the same problems and all of that. But I don't think of myself. I just think of my patients. And sometimes I'm in, I used to be in a survivorship conference and it is like I'm listening and talking about science, and then I'll realize they're talking about me too. So that's good in some ways because I don't ever want to go into a room and think about me then I shouldn't be doing this job. So there's work this important service. So that hasn't happened and I'm grateful for that.
Gail Hogan: Thank you Dr. Ramaswamy, for sharing everything. Thank you so much. 
Bhuvana Ramaswamy, MD: Thank you for giving this opportunity and the ability to share my story. Thank you.
Gail Hogan: And thank you for joining us for Health Talks.
[On-screen text: 
Ohio State Health & Discovery Health Talks
Health.osu.edu]