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Dr. Lee: Good afternoon, everyone. Welcome to the show. I'm your host, Dr. Vivian Lee. I'm the Senior Vice President of the University of Utah Health Sciences. Today, we're going to talk about breast cancer. About one in eight women will develop breast cancer in her lifetime, and it is the second leading cause of cancer death in women.
One of the misunderstandings about breast cancer that we're just starting to understand now better is the fact that breast cancer is not just one disease, but it's actually many different diseases. That's a really important point to understand. Because breast cancer is different diseases, it means we have to have different treatments for women with breast cancer.
My guest today is Dr. Alana Welm, who's a researcher at the University of Utah's Huntsman Cancer Institute. Dr. Welm and her colleagues are making news all over the world because they have found a way to grow pieces of a woman's breast cancer in mice, and that's really going to transform the way we think about breast cancer treatment.
Now, I have read that your research means that we're going to treat women in a very different way where in the past we might try a treatment and it may work or it may not work. The women almost feel like they might be guinea pigs because we don't know how to treat them. Instead, your approach with these mice is almost like making a guinea pig for every patient. Is that a fair description of your work and its implication?

Dr. Welm: That's right. It's a science that's telling us now that breast cancer is probably more, like, ten different diseases. Currently, in the clinic, it's treated as though it were, really, three types of breast cancer. What we're doing is trying to personalize the therapy so that we can grow an individual person's tumor in a mouse and actually use that mouse or that tumor line as a way to determine what are the best therapies for that particular women are.

Dr. Lee: Well, if there are really ten different types and we only know about three, then what does it mean if a woman comes in now? If a woman comes into our clinic at the Huntsman Cancer Institute, how do we treat them now?

Dr. Welm: Currently, breast cancer is heavily over treated, believe it or not. So, we really are treating ten women for the benefit of three. We know that about 30% of breast cancer patients will go on to develop a relapse or a metastasis, and metastasis is what kills patients with breast cancer. Because we cannot determine which three women out of the ten will go onto develop metastatic disease, they are almost all getting treated with really toxic chemotherapies. So one of the goals of our study is to be able to use these tumors grown in mice to determine which ones are the most aggressive ones and then modify treatments according to that particular tumor.

Dr. Lee: One of the most interesting aspects of your work was that when you took these pieces of a woman's breast cancer and you put them into mice, the behavior of those tumors actually was just like when they're in people, right? They not only grew like breast cancers, but they also metastasized. What was it about how you did it that was different from what everyone else had previously tried to do and failed?

Dr. Welm: What we did was expand on an idea that we don't want to culture the tumors before we put them in the mice. So we don't want to put them in the lab on a petri dish like everybody had done before. Instead, we put them directly into the mouse breast tissue or the mouse mammary gland. This environment is so much like the human breast that it allowed these tumors to not only grow, but also to behave very similar to how tumors behave in patients.

Dr. Lee: One of the questions that came to my mind when I first read about this research was, won't it be easier to just take a piece of the breast cancer tissue, look at the DNA of it, and then figure out which of those ten types it is just from that?

Dr. Welm: We are doing that. We're examining the mutations in individual tumors. However, we believe that you have to combine some functional analysis of the biology of that tumor together with the genetic information. So just knowing that there's a mutation in a gene doesn't necessarily tell us about how that tumor will behave in terms of metastasis or in terms of response to therapy. Our idea is to really combine that genetics analysis with a functional assay of tumor biology and tumor behavior in order to make the best treatment decisions.

Dr. Lee: It's sort of, like, that old line that it's not just the genes but the genes and the environment? Just putting some of those breast cancer cells somewhere in the mice, but that didn't work but putting it in the breast tissue itself worked. So there's something about the genes and environment relationship that's important.

Dr. Welm: That's exactly right. The other advantage to using this type of an approach is being able to modify the genetics of a mouse in concert with asking about tumor biology gives us a chance to actually examine the interaction between the genetics, the tumor biology, and the host response to the tumor.

Dr. Lee: We have some questions from some listeners online. Laurie, in the West Valley asks this question. "The women in my family have breast cancer. My mother had it. Two of my aunts had it, and now my sister has it. What does that mean for me, and what does this research mean for people like the women in my family?"

Dr. Welm: We know that cancer is a genetic disease, meaning it can be hereditary. As you probably know, we made the original discovery of the BRCA mutations.

Dr. Lee: The breast cancer genes.

Dr. Welm: The breast cancer genes that are carried through certain families and contribute to a small proportion of breast cancer, but those patients who carry those genes have very, very high risk of breast cancer. That type of inheritance is what seems to be manifested in this family. Partly as a result of these kinds of discoveries in Utah, we have a fantastic high-risk breast cancer clinic that's directed by Dr. Saundra Buys at the University of Utah and Huntsman Cancer Institute. They can test people for these genes. They can provide genetic counseling as to how they might want to modify either their lifestyle or even take surgical precautions for breast and ovarian cancer in the case of BRCA mutation. They actually follow these patients. So rather than that just being the end of, you know, "Okay, here's mutation, and this is what it means for you," we actually want to be able to follow them with high screening.

Dr. Lee: Here's another question from Sandra in Murray. Sandra asks about men. "Can men get breast cancer?"

Dr. Welm: Men do get breast cancer. It's relatively rare. It's only about one percent of breast cancer that happens in men, but it is a problem, and it's not very well recognized.

Dr. Lee: Does it run in families the same way as women? We don't know?

Dr. Welm: We don't know. Yeah.

Dr. Lee: Since it's so rare, we just haven't done enough research in that. Well, Dr. Welm, thank you so much for being my guest today.

Dr. Welm: My pleasure.

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Interviewer: My name is Vivian Lee. I'm the senior vice president for health sciences at the University of Utah, and today we're going to talk about the cold. This can mean dangerous medical problems for people that are exposed to the cold for long periods of time and even short periods of time. Joining me today is Dr. Amalia Cochran, assistant professor of medicine at the University of Utah's department of surgery. She's also an attending surgeon in the university hospital's burn unit and a leading expert on frostbite. Welcome to the show.

Dr. Amalia Cochran: Thank you very much.

Interviewer: We had an experience that made me have to go online and look up frostbite and I realized there wasn't as much information as I would hope. My daughter came back. She was fine after a whole day of skiing, and then she got into the bathtub and she started screaming because she said her feet were really painful and then the tips of her toes were dark red, almost bluish. At that point in time you can imagine I just panicked and tried to look online. I thought, here you are, the expert, let me ask you, what was happening with her? How could I have prevented that?

Dr. Amalia Cochran: It honestly sounds to me like she probably had a case of frost nip. When you're out skiing you've got a prolonged exposure, as does anyone who's outdoors during this weather. The fact that prior to that exposure to the warm water bath she hadn't really had any significant complaints and you hadn't really noticed anything different . . .

Interviewer: No, and is that because you have numbness so you don't even realize what's happening?

Dr. Amalia Cochran: Precisely. There is numbness with frost nip and you see very few changes in the skin if someone has a case of frost nip.

Interviewer: Frost nip is different from frost bite?

Dr. Amalia Cochran: Frost nip is the extremely mild form of frost bite. The way that we tend to differentiate between them is that frost bite involves tissue changes where the skin will actually blister up versus frost nip where there is some of that damage to the skin and the soft tissue but not to the level where it blisters.

Interviewer: Is it blistering because the tissue is actually freezing? What's actually happening there in the skin?

Dr. Amalia Cochran: There are really two different things that occur in the skin with a frost bite or a frost nip injury. One of those is the direct cold injury from the temperature. That impacts the tissues. They do freeze. Little crystals form in them. The other phenomenon that occurs in association with that is ischemia where there is poor blood flow to the cold effected areas. Initially, when the outdoor temperature drops or when we're exposed to lower temperatures somewhere in the neighborhood of 50 degrees fahrenheit, there's a cold induced phase of dilation that occurs.

Interviewer: Blood vessels expand. All of a sudden this blood rushes back in, and then what happens?

Dr. Amalia Cochran: Right. But then after that they constrict. They narrow back down and so the blood flow diminishes.

Interviewer: One of the things about this that worries me is that because of the numbness the kids don't even seem to know that it's happening, so how do we know that that damage is occurring?

Dr. Amalia Cochran: Cold checks are what are recommended in the Alpine mountaineering literature. I think they apply to those of us that are recreational outdoor in the winter as well. The concept of cold checks is that you get yourself to a relatively sheltered location, and I phrase it that way since this is from the Alpine mountaineering literature because there would be a relative shelter if you're skiing, you can say, hey, let's take a hot chocolate break after an hour and a half, and go in and check fingers, check toes.

Interviewer: We do them every half hour sometimes.

Dr. Amalia Cochran: Some days that's really appropriate. You can check everyone's fingers, check everyone's toes. If you notice that the fingertips or the toes are looking particularly pale, if they start getting a little bit woody in terms of how they feel, if they're not as soft as they normally feel, any of those sort of characteristics, that would make you concerned that you may have the early phases of a cold injury occurring.

Interviewer: How can we prevent it?

Dr. Amalia Cochran: Preventing it is a little bit tough if you have a love for winter sports. One of the things is that if you are someone who knows that you have circulatory challenges finding ways to keep your fingers and toes warm.

Interviewer: So even when it's not that cold our fingers and toes get kind of cold. We're particularly sensitive to developing it.

Dr. Amalia Cochran: Absolutely. Be mindful. I tell people I have something known as Raynaud's phenomenon, which means that when I get cold my blood vessels in my fingers and my toes clamp down. So I not only very easily get cold fingers and toes but I'm at higher risk for cold injury. So when I ski I have heaters in my boots and my mittens.

Interviewer: Those hand warmer, toe warmer type things?

Dr. Amalia Cochran: They're actually battery packs.

Interviewer: Oh, I didn't know they made that.

Dr. Amalia Cochran: Yeah, they're a little spendy but they're worth it. I whine a lot less and I have to take fewer breaks.

Interviewer: But short of that, you recommend the hand warmers and toe warmers?

Dr. Amalia Cochran: They're definitely helpful.

Interviewer: Dr. Cochran, you're not only an expert in frostbite but you're also a leader in burn injuries. I noticed we recently had an avalanche victim who had frostbite and was cared for in our burn unit. Maybe you can explain to us this relationship. Why are the frostbite patients and the burn patients all cared for by the same people?

Dr. Amalia Cochran: That surprises people and I know our avalanche victim was a little confused when I showed up and introduced myself and said I was a burn surgeon. She gave me this puzzled look. I said, "Trust me. This is going to be okay." There are a couple of reasons that frost bite victims end up in the care of the burn unit, and one of those is because the mechanism of injury, the way that the body works to generate the frostbite injury or the cold injury is actually very similar to what ends up happening if people have a burn injury. The underlying pathophysiology, to use the big fancy word for it, of what causes the tissue damage is very similar. The other part of it is that with more major cases of frostbite when people have blisters or if they don't get treatment in a timely fashion they can even have gangrene where the tissues die, we are experts in managing soft tissue loss and getting areas of soft tissue loss closed or covered because of the fact that that's what we do with burns. So it ends up making our frostbite practice a very logical extension of what we're already doing.

Interviewer: One of the things I read online when I was reading about this was that you're not supposed to rub the tissues. Why not?

Dr. Amalia Cochran: That's an old wives tale. Historically, people were advised to remove their gloves and their boots and rub the area with snow even to help with cold injury if they thought they were getting cold injury. The problem with doing that is you extend the damage in the soft tissues with the friction. So it's actually not helpful to do that

Interviewer: So the tissue is already pretty fragile and if you're rubbing it you're just making the damage worse.

Dr. Amalia Cochran: Right. So the recommendation for rewarming now is a 40 degree centigrade, which is around 100 degree fahrenheit, warm water bath.

Interviewer: Is 100 degrees about a normal temperature bath?

Dr. Amalia Cochran: It would be a warm bath.

Interviewer: A warm bath.

Dr. Amalia Cochran: Yes.

Interviewer: I was always told that you need to keep your central body really, really warm and if you kept your trunk warm your extremities would sort of take care of themselves. But you're sort of saying, no, those hand warmers are important too.

Dr. Amalia Cochran: Yes, it's both. You need to keep your core warm because of the risk of hypothermia, but when you're looking at a risk for frostbite you need to look at keeping your extremity areas, your fingers, your toes, even your nose is an area that's at risk for lower blood flow when you get really cold.

Interviewer: So those face warmers too.

Dr. Amalia Cochran: Yes.

Interviewer: Well, Dr. Amalia Cochran, thank you so much for being my guest today.

Dr. Amalia Cochran: Thank you, Dr. Lee.

Announcer: We're your daily dose of science, conversation, medicine. This is The Scope. University of Utah Health Sciences Radio.

There's a great quote by Thomas Edison that I love. "If there's a better way, find it."

I think if you have that approach when you look out in the world, you realize that there's always a better way to do what we're doing now. One of the things that's interesting about being in an academic medical center is that you're not just a healthcare delivery system, you have students, and trainees around, and then of course you have many, many researchers.

It's really in that environment is that you can come up with some of the most creative solutions that we need in healthcare, because you have the brilliance of these researchers, and then you're training students, and trainees who are always questioning "Why do we do things this way? Why can't we do it that way? "

Because we have the resources to answer their questions through our researchers, I think we have the opportunity to create whole new ways of thinking that we never did before.

I'm very motivated when I think there's a vision that seems very clear to me, that requires bringing together people from all different backgrounds, from all different perspectives, and getting them to work together successfully.

The value added comes from different backgrounds, different life experiences, trained in different fields of specialty, creativity. And the great new ideas come at those interfaces.

All of us feel a responsibility to train the next generation of researchers, educators, and healthcare providers. As a result we're not just looking at trying to solve the problems today for tomorrow, but we're looking at trying to solve them for years to come.

My highest hopes for the University of Utah are that we really make a difference to the world, we make people better, and healthier, and happier.

The pieces are already here, the talent is already here, what we really need to be able to do is to allow that talent to flourish, and to provide the overall direction for where we want to go. And then kind of step out, get out of the way, and let everyone move us forward.

To know that individually those people are all doing great things, and they're advancing in their own fields, but by bringing everyone in that room together, and to feel those sparks go off, it's incredibly satisfying.