Reigniting the White House Cancer Moonshot in GynOnc & Breast Cancers
DCI oncologists blaze the trail
Last month, three Duke Cancer Institute faculty in the Department of OB-GYN, Division of Gynecologic Oncology — Brittany Davidson, MD; Haley Moss, MD, MBA; and Angeles Alvarez Secord, MD, MSc — and a DCI faculty member in the Department of Medicine, Division of Population Health Sciences (Arif Kamal, MD, MBA, MHS) participated in national-level events under the auspices of the White House Cancer Moonshot Initiative.
First launched in 2016 by the Obama administration and led by then-Vice President Joe Biden to “accelerate scientific discovery in cancer, foster greater collaboration, and improve the sharing of cancer data,” the Cancer Moonshot was reignited in February 2022 by President Joe Biden and First Lady Jill Biden, Ed.D. The new goals are to “reduce the cancer death rate by half within 25 years and to improve the lives of people with cancer and cancer survivors.” (The Cancer Moonshot was not active during the Trump administration.)
In October, the focus was on breast and gynecologic cancers.
White House Launches American Cancer Society National Roundtables on Cervical Cancer & Breast Cancer
On October 24, Arif Kamal, MD, MBA, MHS, the American Cancer Society's first-ever chief patient officer, and Brittany Davidson, MD, joined the White House launch of American Cancer Society national roundtables on cervical cancer and breast cancer — multi-sector partnerships to tackle the most complex problems across the cancer continuum.
Helmed by First Lady Jill Biden Ed.D, American Cancer Society, CEO Karen E. Knudsen, MBA, PhD, and with special guest Mary J. Blige, the event was held in the White House State Dining Room with President Abraham Lincoln looking on.
Davidson, an Associate Professor in the Department of OB-GYN, Division of Gynecologic Oncology, was invited as she's a member of the steering committee of the American Cancer Society National Roundtable on Cervical Cancer (ACS NRTCC), which aims to “reduce barriers to care, eliminate disparities, reduce harms, and promote new technologies in all persons with a cervix.” She joins a network of community members, organizations, and institutions "making a coordinated effort to accelerate the elimination of cervical cancer by addressing health disparities in unscreened and under-screened individuals.”
According to the ACS, 50% of cervical cancer diagnoses are in never-screened people, while 10% of diagnoses are in under-screened individuals. There’s been a more than 50% decrease in cervical cancer incidence and mortality over the past three decades, largely due to screening, and the ACS NRTCC wants to keep that momentum going.
Because the main cause of cervical cancer is long-lasting infection with certain cancer-causing types of human papillomavirus (HPV) — regular screening for HPV is recommended. Additionally, Pap smears may catch early changes to the cervix that can lead to cervical cancer if not addressed appropriately. When cervical cancer is detected early, per ACS, this “greatly improves the chances of successful treatment.”
Davidson said the White House launch marked the beginning of a multi-year effort aimed at eliminating cervical cancer in the U.S. and with it, the suffering of patients and caregivers affected by this preventable cancer.
"The American Cancer Society round table model has a proven track record in fostering partnerships to solve complex public health problems. As a gynecologic oncologist, I look forward to collaborating with patient advocates, public health experts, and other clinicians as we look to a future without cervical cancer," said Davidson. "I truly believe this is possible!"
Aiming for the Moon(shot): A VA Cancer Cabinet Community Conversation on Breast and Gynecologic Cancers Convenes
On October 13, Haley Moss, MD, MBA, who's not only a DCI gynecologic oncologist, but also leads the U.S. Department of Veterans Affairs (VA) Breast and Gynecologic Oncology System of Excellence, and Angeles Alvarez Secord, MD, MSc (associate director, Clinical Research, DCI Gynecologic Cancer Disease Group) participated in a virtual White House Cancer Cabinet Community Conversation on Breast and Gynecologic Cancers moderated by Carolyn Clancy, MD, Assistant Under Secretary for Health for Discovery, Education, and Affiliate Networks at the Veterans Health Administration.
They joined VA health leaders, three oncology faculty from Memorial Sloan Kettering Cancer Center and UCLA Health, and Veteran patients and survivors, on the panel, which focused on equitable care and expanded access to screening, testing, treatment, and clinical trials, in breast and gynecologic cancers.
The Breast and Gynecologic Oncology System of Excellence was established last fall, with Moss as its inaugural director, by the VA National Oncology Program Office “to address the growing needs of Veterans diagnosed with breast, uterine, cervical, ovarian and vulvovaginal cancers.” The needs are growing, Moss says, because the population of women Veterans is growing. At 11% of all U.S. Veterans, women are the fastest-growing group within the Veteran population; this percentage is projected to increase to 18% by 2040.
“In the past two decades, there’s been an unprecedented growth of women Veterans seeking medical care through the Veterans Health Administration,” says Moss.
Through the national teleoncology program, the Breast and Gynecological Cancer System of Excellence is providing breast and gynecological oncology services to Veterans who would have previously been referred to the community for the management of these diagnoses.
“As any patient who has had breast cancer knows, you see a radiation oncologist, a medical oncologist, and a breast surgeon … and for a lot of Vets, that means seeing providers within the VA, but also seeing providers outside the VA,” said Moss, during the virtual panel. “We’re building a care coordination infrastructure to provide additional navigation support to women Veterans, who may need to go between the VA and other health systems as they navigate their (breast and gynecological) cancer care… And we are developing a quality dashboard to assess whether Veterans are receiving care at both VA and non-VA facilities and that they're receiving evidence-based care.”
Moss drew attention to three new pieces of legislation in the areas of breast and gynecologic oncology — the MAMMO Act, the SERVICE Act and the PACT Act — that were passed by Congress over the summer to increase and expand screening, testing, and treatment opportunities for Veterans.
The PACT Act allows the VA to expand care and benefits to more veterans who have been exposed to environmental exposures during their military service such as burn pits and other toxic substances, and expands the types of cancers that are now presumed to be service-connected disabilities, including breast and gynecologic cancers. (Gynecologic cancers, in this case, includes cervical, ovarian, endometrial, uterine, vaginal, vulvar, tubal, and peritoneal cancers.)
Because of the PACT Act, veterans with these cancers can access:
- cutting-edge clinical trials and treatment through the Breast and Gynecologic System of Excellence
- precise diagnostic testing through the VA’s National Precision Oncology Program
- cancer care navigators to guide veterans with breast and/or gynecologic cancer treatment and other needs
The SERVICE Act (Supporting Expanded Review for Veterans in Combat Environments) extends access to mammograms for all female veterans who served in areas with burn pits or other toxic exposures, regardless of their age, symptoms, or family history. Moss said her office is also working with the VA to extend these programs to male Veterans who might be at risk for breast cancer.
The MAMMO Act (Making Advances in Mammography and Medical Options for Veterans), expands the range of breast imaging, testing, and treatment services offered to Veterans with breast cancer.
“The bill emphasizes the need for delivering screening, particularly in rural areas, where there are several facilities that do not have mammography,” said Moss. “In certain areas, there's a pretty long wait list in order to get your mammogram.”
The bill will also ensure that all Veterans with breast cancer have access to appropriate genetic and molecular testing and will expand Veterans' access to clinical trials through partnerships with NCI-designated cancer centers.
Breast surgical oncologist Carolyn Menendez, MD, has recently joined the VA — after having served as director of Clinical Cancer Genetics at DCI for the past three years — to lead efforts to expand access to germline (hereditary) testing through telehealth platforms. Menendez, an assistant professor in the Department of Surgery at Duke, is working with Michael Kelley, MD, director of the VA National Oncology Program Office, on this mission to deliver equitable access to genetics services via teleoncology.
In addition to his national VA role, Kelley is Chief of Hematology and Oncology and a thoracic medical oncologist with the Durham VA Health Care System. (As a professor of in the Department of Medicine, Division of Medical Oncology, Kelley focuses on lung cancer research.) Both Menendez and Kelley are DCI members.
Angeles Alvarez Secord, MD, MSc, President-Elect of the Society of Gynecologic Oncology, was asked by Clancy how to expand clinical research opportunities in the general population of cancer patients to ensure that studies are more diverse — representative of the general population. According to the FDA, only 8% of participants in clinical trials that led to FDA approvals were Black, which Secord says, “limits the ability to assess underlying prognostic factors and explore underlying tumor biology.”
“We need to ensure that that we move into an era where there's more trust with our patients and that they're willing to participate in trials,” Secord said in response to Clancy’s question. “Dr. Nadine Barrett at Duke has developed a program that's called “Just Ask.” We can't assume, have our bias, that patients won't participate in clinical trials. We need to ask all our patients about participation, and we need to offer ways that we can reduce barriers to participation in trials like offering to cover transportation and childcare costs.”
According to the latest figures from the VHA, about 43% of women who use VHA Services belong to a racial or ethnic minority group. The majority within this group are Black/African American women (30%), which is not surprising given that, according to the U.S. Department of Labor, Black women Vets account for 19% of all women Vets in the U.S.
Clancy noted while there’s been some narrowing of the racial gap and mortality trends for most cancers, the opposite is true for uterine cancers. She asked Secord to shed light on why studies show that Black women in particular are more likely to be diagnosed with uterine cancer (aggressive non-endometrioid carcinoma) than White women and are twice as likely to die from the disease.
“When we talk about Black patients being at higher risk, this is something that we're incredibly concerned about. We’ve identified that Black women tend to have these cancers that are more aggressive — the serous histology, cancers that have P53 mutations, and the copy-number-high tumors — that portend a worse prognosis,” said Secord, while noting that the reasons behind the disparity are likely multi-factorial.
Uterine cancer is the fourth most common cancer and the sixth leading cause of cancer mortality among women overall. The average annual increase in mortality from uterine cancer is greater than from any other malignancy in either males or females. Three of Secord's colleagues at Duke — Moss, Laura Havrilesky, MD, MHSc, and Evan Myers, MD, MPH — were awarded $1.2 million in funding from the National Cancer Institute Cancer Intervention and Surveillance Modeling Network last year to study ways to reduce uterine cancer mortality through primary prevention, screening, and treatment approaches.
"Despite the availability of diagnostic tests to detect uterine cancer, screening is not routine and evidence-based recommendations for screening and prevention are lacking," says Havrilesky, adding that "for those women diagnosed with uterine cancer, optimal treatment strategies and precision therapeutics are often uncertain."
Secord compares the emergence of new and better therapies in gynecologic cancers — most recently PARP inhibitors that are pivotal in the treatment of ovarian, tubal and peritoneal cancers — to the rapid development, in recent years, of novel therapies in breast cancer.
PARP inhibitors, niraparib, olaparib, and rucaparib, she explained, are prescribed for a variety of different indications and are most commonly used for maintenance treatment for patients with ovarian cancer, fallopian tube cancer, or primary peritoneal cancer after chemotherapy.
“We do know that there is improvement of not just disease control, but we actually have new data that shows improved overall survival for patients who have BRCA 1 and BRCA 2 mutations,” said Secord.
Secord also mentioned biomarker-based immunotherapies such as pembrolizumab, dostarlimab, and lenvatinib, which are approved for use in patients with certain types of gynecologic cancers. Pembrolizumab is used in advanced/metastatic cervical cancers that overexpress PDL 1 and in certain types of endometrial cancers, whether alone or in combination with lenvatinib.
“We also have this really cool drug that's been approved in cervical cancer that's an antibody drug conjugate,” said Secord, describing how tisotumab vedotin-tftv (Brand: Tivdak) acts “like a heat-seeking missile where it identifies the target on the cancer cell, delivers the cancer drug to that cancer cell and causes that cancer cell to hopefully die, but then it protects the rest of the body so there's not as much toxicity to the normal cells.” There still are side effects, but severe side effects are less common.
“Gynecologic cancer treatments have come a long way in the last 10 years and it's really exciting to be a part of this progress. We want to help our patients live longer and better lives,” said Secord.
This is a message that’s bound to resonate with all administrators, researchers, and clinicians, who work with and treat Veterans and non-Veterans alike.
“In February, the President and I reignited the Cancer Moonshot with a bold ambition: to build a world where the word cancer forever loses its power. We’re doing that by breaking down the barriers that hold back critical collaboration and research. We’re investing more money than ever before in new treatments and therapies, and making sure people can get the best, cutting-edge care sooner. And we’re creating better ways to help patients and their loved ones understand and navigate their care. So, what does the world we’re building look like? It’s a world where people don’t have to face complicated care plans alone. Where they don’t lose their life savings just trying to survive. Where treatments are less toxic — and patients and the people who love them have the support they need to thrive. Where a diagnosis is no longer a death sentence.” — First Lady Jill Biden, Ed.D. in prepared remarks at the October 24, 2022, Cancer Moonshot Event with the American Cancer Society and Special Guest Mary J. Blige