- Medical Oncology
- Breast Cancer
- Cancer Survivorship
Editor-in-Chief Cancer.Net, American Society of Clinical Oncology (2015 - Present)
Director Cancer Survivorship Program, Stanford (2016 - Present)
Medical Education:Dartmouth Geisel School of Medicine Office of the Registrar (1982) NH
Board Certification: Medical Oncology, American Board of Internal Medicine (1997)
Fellowship:Dana Farber Cancer Institute Hematology Oncology Fellowship (1989) MA
Board Certification: Internal Medicine, American Board of Internal Medicine (1985)
Residency:Beth Israel Deaconess Medical Center (1985) MA
Community and International Work
Building Capacity for Cancer Care
ASCO (American Society of Clinical Oncology)
Low and Medium Resource Countries
Opportunities for Student Involvement
Literacy and Language
Leveraging Mindsets to Improve Health and Wellbeing in Patients With Cancer
Primary Objectives: Mindsets have been rigorously studied in the domains of development, education, and more recently, in health and disease. However, there are no large-scale longitudinal studies of the mindsets held by cancer patients and how they may affect treatment outcomes, physical health, and psychological well-being. This randomized, single-blind, treatment-as-usual (TAU) control study aims to assess (1) mindsets at four time points spanning from the point of diagnosis to six weeks post-treatment to patients who are newly diagnosed with cancer and undergoing treatment with curative intent, and (2) the impact of a brief but targeted mindset intervention to help instill more useful mindsets about the nature of cancer and the role of the body on patient reported measures of physical and psychological health. This study aims to add to the existing literature on psychosocial interventions for cancer patients and survivors while addressing the substantial time and cost limitations of traditional interventions. It also contributes to the body of research indicating that mindsets play an important role in both health and wellbeing. Secondary Objectives: This study has two secondary objectives. First, we aim to determine the impact of patient mindsets on measures of treatment (treatment efficacy and treatment related adverse events) and psychosocial health (stress, coping, mood, emotions). Second, we aim to understand the relationship between patient mindsets and biomarkers of immune and inflammatory processes in patients undergoing cancer treatment
Stanford is currently not accepting patients for this trial. For more information, please contact Alia J Crum, PhD, 650-725-2418.
The incidence of hematologic cancers after breast cancer. A 35-year population-based cohort study in Denmark
WILEY. 2019: 75
View details for Web of Science ID 000481785600147
Risk of primary urological and genital cancers following incident breast cancer: A Danish population-based cohort study
WILEY. 2019: 79
View details for Web of Science ID 000481785600155
Risk of primary gastrointestinal cancers following incident breast cancer: A Danish population-based cohort study
WILEY. 2019: 81
View details for Web of Science ID 000481785600159
Contemporary management of breast cancer during pregnancy and subsequent lactation in a multicenter cohort of young women with breast cancer.
The breast journal
The incidence of breast cancer diagnosed during pregnancy is increasing. We sought to characterize patient, treatment, pregnancy and lactation factors among young women with newly diagnosed breast cancer during pregnancy in a prospective cohort study. We identified all women who were pregnant when diagnosed with invasive breast cancer among those enrolled in the Young Women's Breast Cancer Study (NCT01468246), and collected details on pregnancy, birth and lactation from surveys, and treatment information medical record review. Of 1302 enrolled participants, 976 women with invasive breast cancer completed full baseline surveys, among whom 39 (4.0%) patients reported being pregnant at diagnosis. Median age at diagnosis was 34years (range: 25-40), with stage distribution: I, 28%; II, 44%; III, 23%; and IV, 5%. 74% of patients (29/39) had grade 3 tumors, 59% (23/39) ER-positive, and 31% (12/39) HER2-positive disease. 23 (59%) had surgery during pregnancy, 4 (17%) during the first trimester. Among the women who had surgery during pregnancy, 61% (14/23) underwent lumpectomy, 35% (8/23) unilateral, and 4% (1/23) bilateral mastectomy. All patients who had chemotherapy (51%, 20/39) received it in second and third trimesters, and had ACx4. There were 31 live births, 2 spontaneous, and 5 therapeutic abortions. Among live births, 16 (41%) were before 37weeks of gestation. Three women reported breastfeeding. Within 6months after delivery, comprehensive staging in 13 patients showed upstaging in four patients. In a contemporary cohort of young women with breast cancer, pregnancy at diagnosis is relatively uncommon. Treatment during pregnancy can generally be consistent with standard surgical and chemotherapy approaches, with attention to timing of therapies. Longer-term outcomes including effects of some timing issues including delayed use of anti-HER2 therapy on patient outcomes warrant further research.
View details for DOI 10.1111/tbj.13431
View details for PubMedID 31318125
- Patient-Reported Outcomes for Cancer Patients Receiving Checkpoint Inhibitors: Opportunities for Palliative Care-A Systematic Review JOURNAL OF PAIN AND SYMPTOM MANAGEMENT 2019; 58 (1): 137-+
Nonadherent behaviors among young women on adjuvant endocrine therapy for breast cancer.
BACKGROUND: Young age is a known factor associated with suboptimal adherence to endocrine therapy (ET) for adjuvant breast cancer (BC) treatment. This study was aimed at assessing nonadherent behaviors and associated factors among young women with early-stage hormone receptor-positive BC.METHODS: As part of a multicenter, prospective cohort of women with a diagnosis of BC at or under the age of 40years, participants were surveyed 30months after their diagnosis about adherent behaviors. Among those who reported taking ET, adherence was measured with a 3-item Likert-type scale: Do you ever forget to take your ET? If you feel worse when you take your ET, do you stop taking it? Did you take your ET exactly as directed by your doctor over the last 3months? Women reporting at least 1 nonadherent behavior were classified as nonadherers. Variables with a P value<.20 were included in a multivariable logistic model.RESULTS: Among 384 women, 194 (51%) were classified as nonadherers. Univariate factors that retained significance in the multivariable model included educational level (odds ratio [OR], 0.50 for high vs low; P=.04), level of social support according to the Medical Outcome Study Social Support Survey (OR, 0.98 per 1 point; P=.01), and confidence with the decision regarding ET measured on a 0 to 10 numerical scale (OR, 0.63 for high vs low; P=.04).CONCLUSIONS: Findings from this study could help to identify young patients at higher risk for nonadherence. Interventions adapted to the level of education and aimed at reinforcing support and patients' confidence in their decision to take ET could improve adherence and associated outcomes in this population.
View details for DOI 10.1002/cncr.32192
View details for PubMedID 31120571
- Genomics of HER2+breast cancer in young women before and after exposure to chemotherapy (chemo) plus trastuzumab (H). AMER SOC CLINICAL ONCOLOGY. 2019
Differences among Asian/Asian American, and Caucasian breast and gynecologic cancer patient reported survivorship needs, symptoms, and illness mindsets (N=220).
AMER SOC CLINICAL ONCOLOGY. 2019
View details for Web of Science ID 000487345804287
- Variations in patient-reported outcome (PRO) collection and reporting in novel FDA approved anticancer therapies. AMER SOC CLINICAL ONCOLOGY. 2019
- Does the innovative 4R Care Delivery Model improve timing and sequencing of guideline recommended breast cancer care in safety net and non-safety net centers? AMER SOC CLINICAL ONCOLOGY. 2019
- Does the innovative 4R Cancer Care Delivery Model improve patient self-management in safety net and non-safety net centers? AMER SOC CLINICAL ONCOLOGY. 2019
- Diagnostic and treatment delays in young women with breast cancer. AMER SOC CLINICAL ONCOLOGY. 2019
Body weight changes in young breast cancer survivors and associated predictors.
AMER SOC CLINICAL ONCOLOGY. 2019
View details for Web of Science ID 000487345804243
"If you don't ask, you won't know": Do patient reported outcome (PRO) instruments capture the symptom experience of patients treated with immune checkpoint inhibitors (ICIs)?
AMER SOC CLINICAL ONCOLOGY. 2019
View details for Web of Science ID 000487345804248
The impact of blinding on patient-reported outcomes (PROs) in randomized controlled trials of immune checkpoint inhibitors versus traditional chemotherapies.
AMER SOC CLINICAL ONCOLOGY. 2019
View details for Web of Science ID 000487345803187
- Identifying distinct trajectories of change in young breast cancer survivors' sexual functioning PSYCHO-ONCOLOGY 2019; 28 (5): 1033–40
Patient reported outcomes for cancer patients receiving immunotherapy: opportunities for palliative care - A Systematic Review.
Journal of pain and symptom management
CONTEXT: Immune checkpoint inhibitors (ICIs) are increasingly used to treat a variety of cancers, but comparatively little is known about patient-reported outcomes (PROs) and health-related quality of life (HRQoL) among patients receiving these novel therapies.OBJECTIVES: We performed a systematic review to examine PROs and HRQoL among cancer patients receiving ICIs as compared to other anticancer therapies.METHODS: We systematically searched PubMed, CINAHL, Embase, Web of Science, and Scopus, using search terms representing ICIs, PROs and HRQoL on August 10, 2018. Eligible articles were required to involve cancer patients treated with ICIs and to report PROs and/or HRQoL data.RESULTS: We screened 1,453 references and included 15 publications representing 15 randomized controlled trials in our analysis. Studies included several cancer types (melanoma, lung cancer, genitourinary cancer, and head/neck cancer), utilized four different ICIs (nivolumab, pembrolizumab, atezolizumab, and ipilimumab), and compared ICIs to a wide range of therapies (chemotherapy, targeted therapies, other immunotherapy strategies, and placebo). Studies utilized a total of seven different PROs to measure HRQOL, most commonly the European Organisation for the Research and Treatment of Cancer core quality of life questionnaire (EORTC QLQ-C30) (n = 12, 80%). PRO data were reported in a variety of formats and at a variety of time points throughout treatment which made direct comparison challenging. Some trials (n=11, 73%) reported PROs on specific symptoms. In general, patients receiving ICIs had similar to improved HRQoL and experiences when compared to other therapies.CONCLUSION: Despite the broad clinical trials experience of ICI therapies across cancer types, relatively few randomized studies reported patient PROs and HRQoL data. Available data suggest that ICIs are well-tolerated in terms of HRQoL compared to other anticancer therapies although the conclusions are limited by the heterogeneity of trial designs and outcomes. Currently used instruments may fail to capture important symptomatology unique to ICIs, underscoring a need for PROs designed specifically for ICIs.
View details for PubMedID 30905677
"DID YOU FEEL THE EARTH SHAKE?" AN ONLINE CANCER COMMUNITY INTERPRETS RESULTS OF A PRACTICE-CHANGING TRIAL
OXFORD UNIV PRESS INC. 2019: S39
View details for Web of Science ID 000473349400080
Identifying Distinct Trajectories of Change in Young Breast Cancer Survivors' Sexual Functioning.
OBJECTIVES: To identify and characterize distinct trajectories of change in young women's sexual functioning over five years following breast cancer diagnosis.METHODS: Group-based trajectory modeling was applied to the sexual functioning of 896 women diagnosed with stage I-IV breast cancer at age ≤40 years. The Cancer Rehabilitation Evaluation System was used to evaluate women's symptoms of sexual dysfunction annually for five years.RESULTS: Five distinct trajectories of sexual functioning were identified: one asymptomatic, one minimally symptomatic, two moderately symptomatic, and one severely symptomatic trajectory. 12% of women were asymptomatic throughout follow-up. The plurality of women experienced stable mild symptoms (42%). Amongst those with moderate symptoms, some experienced improvement over time (22%) while others experienced deterioration (13%). 11% experienced stable severe symptoms that did not remit over time. Independent predictors of experiencing a symptomatic rather than asymptomatic trajectory (p<0.05, two-sided) included diagnosis with stage 2 versus 1 disease, ER+ disease treated with oophorectomy or ovarian suppression, being partnered, having anxiety, poorer body image, and greater musculoskeletal pain.CONCLUSIONS: We identified distinct trajectories that describe the reported sexual symptoms in this cohort of young breast cancer survivors. The majority of women reported various degrees of sexual dysfunction that remained stable over the study period. There is, however, potential for improvement of moderate and severe symptoms of sexual dysfunction in early survivorship.
View details for PubMedID 30817075
Prognostic Impact of the 21-Gene Recurrence Score Assay Among Young Women With Node-Negative and Node-Positive ER-Positive/HER2-Negative Breast Cancer.
Journal of clinical oncology : official journal of the American Society of Clinical Oncology
The 21-gene recurrence score (RS) assay is prognostic among women with early-stage estrogen receptor-positive (ER+) and human epidermal growth factor receptor 2-negative (HER2-) breast cancer and is used to inform recommendations for chemotherapy. Women ≤ 40 years of age represent a minority of patients studied using gene expression profiles.The Young Women's Breast Cancer Study is a prospective cohort of women diagnosed with breast cancer at age ≤ 40 years and enrolled patients between 2006 and 2016 (N = 1,302). We identified patients with stage I-III ER+/HER2- breast cancer. The RS assay was performed on banked specimens for patients who had not been tested clinically. Distant recurrence-free survival (DRFS) was assessed by TAILORx and traditional RS risk groups among patients with axillary node-negative (N0) and limited node-positive (N1) breast cancer.Among eligible women (N = 577), 189 (33%) had undergone RS testing, and 320 (56%) had banked specimens sufficient for testing. Median follow-up was 6.0 years. Median age at diagnosis was 37.2 years; 300 of 509 patients (59%) had N0 breast cancer, of whom 195 (65%) had an RS of 11-25 and fewer than half (86 of 195; 44%) received chemotherapy. Six-year DRFS rates were 94.4% and 92.3% (RS < 11), 96.9% and 85.2% (RS 11-25), and 85.1% and 71.3% (RS ≥ 26) among women with N0 and N1 disease, respectively.The RS assay is prognostic among young women with node-negative and limited node-positive breast cancer, representing a valuable tool for risk stratification. Disease outcomes with a median follow-up of 6 years among young women with N0 disease and an RS of 0-25, a minority of whom received chemotherapy, and node-positive disease with an RS < 11 were very good, whereas those with N0 disease and an RS ≥ 26 or N1 disease with an RS ≥ 11 experienced substantial risk of early distant recurrence.
View details for DOI 10.1200/JCO.19.01959
View details for PubMedID 31809240
Targeting Mindsets, Not Just Tumors
Trends in Cancer
View details for DOI 10.1016/j.trecan.2019.08.001
Employment trends in young women following a breast cancer diagnosis.
Breast cancer research and treatment
Little is known about how a breast cancer diagnosis and treatment affects job-related outcomes in young women with breast cancer, who are an integral part of the workforce. We sought to describe employment trends among young breast cancer survivors.911 women with non-metastatic breast cancer were surveyed about employment-related outcomes 1 year post-diagnosis. Participants were enrolled in the Young Women's Breast Cancer Study an ongoing, multi-center cohort of women diagnosed with breast cancer at age ≤ 40.Among 911 women, median age at diagnosis was 36 years (range 17-40). Most women (80%, n = 729) were employed 1 year post-diagnosis. Among the 7% (n = 62) employed before diagnosis but who reported unemployment at 1 year, approximately half reported they were unemployed for health reasons. Among employed women, 7% said treatment affected their ability to perform their job. Women with stage-three disease (vs. stage 1 disease, odds ratio (OR): 3.73, 95% CI 1.39-9.97) and those who reported having money to pay bills after cutting back or difficulty paying bills at baseline (vs. having enough money for special things, OR 2.70, 95% CI 1.32-5.52) at baseline were more likely to have transitioned out of the workforce.Our results suggest an impact of disease burden and socioeconomic status on employment in young breast cancer survivors. There is a need to ensure young survivors who leave the workforce following diagnosis are sufficiently supported given the potential adverse psychosocial and financial impacts of unemployment on survivors, their families, communities, and society.
View details for DOI 10.1007/s10549-019-05293-x
View details for PubMedID 31147983
Evaluation of significant genome-wide association studies risk - SNPs in young breast cancer patients.
2019; 14 (5): e0216997
PURPOSE: Genome-wide-association studies (GWAS) have identified numerous single nucleotide polymorphisms (SNPs) that are associated with an increased risk of breast cancer. Most of these studies were conducted primarily in postmenopausal breast cancer patients. Therefore, we set out to assess whether or not these breast cancer variants are also associated with an elevated risk of breast cancer in young premenopausal patients.METHODS: In 451 women of European ancestry who had prospectively enrolled in a longitudinal cohort study for women diagnosed with breast cancer at or under age 40, we genotyped 44 SNPs that were previously associated with breast cancer risk. A control group was comprised of 1142 postmenopausal healthy women from the Nurses' Health Study (NHS). We assessed if the frequencies of the adequately genotyped SNPs differed significantly (p≤0.05) between the cohort of young breast cancer patients and postmenopausal controls, and then we corrected for multiple testing.RESULTS: Genotyping of the controls or cases was inadequate for comparisons between the groups for seven of the 44 SNPs. 9 of the remaining 37 were associated with breast cancer risk in young women with a p-value <0.05: rs10510102, rs1219648, rs13387042, rs1876206, rs2936870, rs2981579, rs3734805, rs3803662 and rs4973768. The directions of these associations were consistent with those in postmenopausal women. However, after correction for multiple testing (Benjamini Hochberg) none of the results remained statistically significant.CONCLUSION: After correction for multiple testing, none of the alleles for postmenopausal breast cancer were clearly associated with risk of premenopausal breast cancer in this relatively small study.
View details for DOI 10.1371/journal.pone.0216997
View details for PubMedID 31125336
Family-building decision aid and planning tool for young adult women after cancer treatment: protocol for preliminary testing of a web-based decision support intervention in a single-arm pilot study.
2019; 9 (12): e033630
Many young adult female (YA-F) cancer survivors who received gonadotoxic therapy will experience fertility problems. After cancer, having a child will often require assisted reproductive technology (ART), surrogacy or adoption. However, there are significant informational, psychosocial, financial and logistical barriers to pursuing these options. Survivors report high rates of decision uncertainty and distress related to family-building decisions. The aim of this study is to pilot test a web-based decision aid and planning tool for family-building after cancer.The pilot study will use a single-arm trial design to test the feasibility and acceptability (aim 1) and obtain effect size estimates of the decision support intervention (aim 2). The target sample size is 100. Participants will include YA-F survivors (aged 18-45 years) who are post-treatment and have not completed desired family-building. A longitudinal prepost design will be conducted. Participants will complete three psychosocial assessment surveys over a 3-month time period to track decisional conflict (primary outcome) and cognitive, emotional, and behavioural functioning (secondary outcomes). After completing the baseline survey (T1; pre-intervention), participants will have access to the decision aid website. Postintervention surveys will be administered at 1-month (T2) and 3-month (T3) follow-up time points. Feasibility and acceptability metrics will be analysed. Pairwise t-tests will test mean scores of outcome variables from T1 to T2. Effect size estimates (Cohen's d) will be calculated. Google analytics will evaluate user engagement with the website over the study period. Baseline and follow-up data will examine measures of feasibility, acceptability and intervention effect size.This will be the first test of a supportive intervention to guide YA-F cancer survivors in family-building decisions and early planning. Study findings will inform intervention development. Future directions will include a randomised controlled trial to test intervention efficacy over a longer time period.NCT04059237; Pre-results.
View details for DOI 10.1136/bmjopen-2019-033630
View details for PubMedID 31888941
- Health after cancer: Early patient experience in a pilot survivorship clinic embedded in primary care. AMER SOC CLINICAL ONCOLOGY. 2018
Online Communities as Sources of Peer Support for People Living With Cancer: A Commentary.
Journal of oncology practice
Online communities are virtual spaces dedicated to hosting conversations between individuals with a common interest. Information can be shared and obtained incrementally, as users can periodically post both questions and responses to other users' questions. Although online communities have been used frequently by patients for a myriad of health issues, much remains to be learned about these resources. In this commentary, we explore the emerging role of online communities as forums for information exchange and sources of support for patients with cancer and caregivers. We discuss selected examples of online communities launched by research institutions, advocacy groups, philanthropic organizations, start-ups, and novel enterprises featuring collaborations between industry, health care professionals, and advocates. We explore the risks and benefits of online communities as perceived by oncology clinicians and provide practical recommendations for improving communication between clinicians and patients about the use of online resources.
View details for PubMedID 30335558
- MODERN CHEMOTHERAPY USE AMONG YOUNG WOMEN WITH EARLYSTAGE ER+/HER2-BREAST CANCER CHURCHILL LIVINGSTONE. 2018: S18
Anxiety and Depression in Young Women With Metastatic Breast Cancer: A Cross-Sectional Study
2018; 59 (3): 251–58
Young adults with cancer experience disruptions in their normal developmental trajectories and commonly experience psychologic distress related to their diagnoses. Young women with metastatic breast cancer (MBC) are at particular risk of adverse mental health outcomes.We sought to determine the prevalence of and factors associated with anxiety and depression symptoms in young women with newly diagnosed de novo MBC.A total of 54 women with newly diagnosed de novo MBC were identified from an ongoing, prospective, multicenter cohort of women diagnosed with breast cancer at age <40. Depression and anxiety symptoms were assessed using the Hospital Anxiety and Depression Scale (HADS). Items assessing socio-demographics, physical symptom burden, social support, and disease and treatment history, with complementary medical record review, were used to assess variables potentially associated with anxiety and depression symptoms.Mean HADS Depression score was 4.4 (standard deviation = 3.7) and mean HADS Anxiety score was 7.9 (standard deviation = 5.0). Eleven (20%) women scored ≥8 on the HADS Depression subscale, the suggested threshold for depression/anxiety screening, and 24 (44%) women scored ≥8 on the HADS Anxiety subscale. In a multivariable model of anxiety, higher physical symptom scores (odds ratio = 4.41, p = 0.005) was significantly associated with higher anxiety scores. None of the other variables improved the model fit.In this study, a considerable proportion of young women with newly diagnosed MBC experienced anxiety symptoms, although depression was less common. Future strategies focused on distress reduction in young MBC patients should focus on physical symptom management as well as anxiety identification and management.
View details for PubMedID 29525523
View details for PubMedCentralID PMC5935568
The Power of Trust.
View details for PubMedID 29710067
Management of side effects during and post-treatment in breast cancer survivors
2018; 24 (2): 167–75
Cancer-related fatigue, insomnia, and cancer-related cognitive impairment are commonly experienced symptoms that share psychological and physical manifestations. One or more of these symptoms will affect nearly all patients at some point during their course of treatment or survivorship. These side effects are burdensome and reduce patients' quality of life well beyond their cancer diagnosis and associated care treatments. Cancer-related fatigue, insomnia, and cancer-related cognitive impairment are likely to have multiple etiologies that make it difficult to identify the most effective method to manage them. In this review, we summarized the information on cancer-related fatigue, insomnia, and cancer-related cognitive impairment incidence and prevalence among breast cancer patients and survivors as well as recent research findings on pharmaceutical, psychological, and exercise interventions that have shown effectiveness in the treatment of these side effects. Our review revealed that most current pharmaceutical interventions tend to ameliorate symptoms only temporarily without addressing the underlying causes. Exercise and behavioral interventions are consistently more effective at managing chronic symptoms and possibly address an underlying etiology. Future research is needed to investigate effective interventions that can be delivered directly in clinic to a large portion of patients and survivors.
View details for PubMedID 28845551
Bridging gaps in breast cancer care: A pilot forum for mental health professionals
AMER ASSOC CANCER RESEARCH. 2018
View details for Web of Science ID 000425489402012
Fertility interest, management and outcomes in young BRCA plus breast cancer survivors
AMER ASSOC CANCER RESEARCH. 2018
View details for Web of Science ID 000425489402194
Fertility concerns and their impact on hormonal therapy decisions in young breast cancer survivors
AMER ASSOC CANCER RESEARCH. 2018
View details for Web of Science ID 000425489401105
- Amani's Silence. oncologist 2017
For Our Patients, for Ourselves: The Value of Personal Reflection in Oncology.
American Society of Clinical Oncology educational book. American Society of Clinical Oncology. Meeting
2017; 37: 765-770
Caring for patients with cancer is a great privilege as well as an emotionally and intellectually challenging task. Stress and burnout are prevalent among oncology clinicians, with serious repercussions for the care of patients. Professional societies must provide guidance for trainees and practicing physicians to mitigate the negative consequences of stress on their personal lives and medical practice. Reflection, reading, and writing about personal experiences provide outlets for fortifying personal reserves and promoting resilience to allow us to recognize the joy and meaning of our work and to forge connections with our peers. Herein, we present some of our own reflections on how and why one might take time to write, and about the power of the written word in oncology and medicine.
View details for DOI 10.14694/EDBK_175520
View details for PubMedID 28561701