January 2016

Dr. May Lynn Quan is a surgical oncologist, specializing in breast cancer. She is an Associate Professor of Surgery and Oncology at the University of Calgary, and is invested in clinical effectiveness, health services research, and women’s health. (Dr. Quan’s Publications)

Dr. Quan is the principal investigator of the RUBY project (www.womensresearch.ca/ruby-study; @wecanruby), coordinated through the Applied Health Research Centre (part of the HUB Health Research Solutions).

The following interview has been edited for clarity and brevity by Dorothy Myers.

What is your area of research?

I’m a surgeon and I specialize in oncology, specifically breast cancer. My area of research is centered on breast cancer outcomes, specifically, delivery and quality of care, with a focus on surgery.

Can you speak briefly about the RUBY project?

Breast cancer in women under 40 is uncommon, accounting for less than 5% of those diagnosed with the disease. As a result, studies supporting treatments for breast cancer lack data on young women and findings based on their older counterparts may not be applicable. Young women have poorer outcomes and the reasons why are likely multifactorial and remain unclear. The RUBY study will create a prospective Canadian cohort of young women with breast cancer, sampling from a variety of settings at 29 sites from across Canada with the ultimate aim to better improve outcomes in this group of women. We have dedicated local surgeon site leads who are recruiting women under 40 to join our cohort at the time of diagnosis, and whom we will then follow over time. We will be collecting standard risk factor variables, such as family history and hormonal exposures, but also unique lifestyle variables such as exercise and diet, in addition to collecting both blood and tumour samples that will create an extensively annotated database on this unique population. We are also asking participants to complete a series of patient reported outcomes about emotional well-being and their experience throughout the treatment process, which will allow us to really hone in on the areas that we are failing at in terms of meeting the needs of these young women and identifying areas where improvements can be made.

Excitingly, four different projects stem from RUBY. The first is out of Women’s College Hospital led by Dr. Kelly Metcalfe, and is looking at the reasons younger women get breast cancer. Specifically, we are looking at the role of genetic mutations. While we know that BRCA mutations are predominant; there are other genetic abnormalities, which are known, but less well studied. We are offering an extended genetic panel to RUBY participants, irrespective of family history, to get a signal on what genetic panels may be more relevant in this age group, which may then inform our provincial partners to perhaps fund different genetic panels for women under the age of 40.

Treatments such as chemotherapy and hormone therapy can limit fertility, so we are looking at improving awareness and referral for fertility preservation through knowledge translation strategies. Dr. Ellen Warner at Sunnybrook Research Institute is heading a project looking at how we, as practitioners, ensure that fertility is addressed during this treatment course for young women in their child-bearing years. Secondly, we are coming up with a way to predict whether or not fertility will be affected, which will help young women decide if they wish to proceed with preservation treatments.

The third study is being led by Dr. Christine Friedenreich at the University of Calgary. Her expertise is in the effect of exercise on breast cancer outcomes. She is leading a group that will focus on detailed physical behaviour and dietary factors that may also have an impact on outcomes for young women.

Finally, Dr. Nancy Baxter at St Michael’s Hospital will be leading multiple studies aimed at improving local therapy for young women. She will be evaluating the role of diagnostic delay in this unscreened population, as well as using integrated knowledge translation with our 29 site leads to improve access to multidisciplinary care. She is also leading a merger of multiple population based datasets from across Canada to create a single resource that will combine long term data on over 3000 young women with breast cancer.

Why did you decide to go into that area of research for your career?

The amazing mentorship and resources I had available working with the people at the Institute for Clinical Evaluative Sciences (ICES) during my first academic position at the University of Toronto were fundamental in shaping my research focus. I was able to take the clinical questions I thought were important and hone my desire to ultimately improve patient care, specifically in the delivery of care, and how our treatment decisions can impact our patient’s outcomes. That’s really what it all boils down to.

My research interest looks at how we can improve care, specifically at the processes involved in the delivery of care, and how our treatment decisions can impact how people do. My interest in young women with breast cancer started with the creation of a population based dataset of women 35 and younger in Ontario to try to determine whether or not doing the lesser surgery of lumpectomy was equivalent to doing a mastectomy, which is the standard for women over 55. We know that younger women recur more frequently and have higher rates of mortality, so we were not really sure that the same thing held true for young women. We were limited by the fact that the data was retrospective and the data was limited in numbers. From this we recognized that moving forward under prospective conditions, we would be allowed to have control over more variables and be more exact about what we want to include in our analysis; and this is realized in the RUBY study!

Can you reflect on what you feel has contributed to your success so far as a researcher?

Honestly, I think having a strong sense of a clinical question I want to answer and being an active clinician have been critical in what drives my desire to do research. The success comes from the support of my colleagues and guidance from my mentors. Having mentors and resources available are critical to establishing any sort of research program. I was fortunate to start my research career in Toronto, where I was shown what is possible to achieve with the right collaborations and infrastructure, and also how to maximize these resources. When I moved to the University of Calgary, I was able to take the experiences and lessons learned from my mentors in Toronto and apply them to my new research environment.

Is there a study that has caused the greatest impact on your career?

My immediate response is to say the RUBY study, but the RUBY study is really a culmination of other studies. There wasn’t a particular study that had the biggest impact on my career, although I’m hoping the RUBY cohort will be my most impactful research program.

In retrospect, it all started with a clinical question. I would actually say that it was a patient who has caused the greatest impact on my career. When I first started in practice, I saw a young woman with breast cancer in clinic. She just had a baby, and her course was very atypical. We just don’t often see 29 year old women with breast cancer. When I talked to her about her two treatment options (lumpectomy vs. mastectomy), I didn’t have the same level of confidence that I would when speaking to a 65 year old woman about whether or not these two treatment options were equivalent.

This patient visit prompted me to look into what research had been done in younger women with breast cancer. I recognized there were a lot of holes; this is an understudied group, it’s very complicated, there are factors at play that aren’t relevant to older women, and we just didn’t know enough about it at the time. It drove me to try and answer the question, “Is a lumpectomy equivalent to a mastectomy for women under 35?” I was fortunate to work with folks at ICES to bring that study to fruition. Now we do have an answer, but we realize it has some limitations, and in order to further answer the question we should perhaps look at all the other factors, which is how the RUBY study came to be. I am hoping RUBY will give us a legacy infrastructure and resource, and act as a platform to carry on more research in the future.

A big motivation to do research is that we want to make patient care better, not only from an oncologic outcome perspective, but also the experience for women. I really think that the RUBY study will allow us to answer questions about clinical outcomes, and because the study’s investigators are all clinicians, we have the vector to try and bring that evidence into practice. I feel really proud of that part, that we have a dedicated, motivated, and keen group of investigators who really want to help answer these questions so that we can improve the way care is delivered to our local patient populations.

How would you define successful research?

I think it all depends on your perspective. For me personally, the drive to conduct research is to try to make things better for the patient population you are studying. And that achievement, to me, is a research success. I’ve always said that 1,000 papers that may, or not, be read or implemented pale in comparison to being able to change one aspect of a delivery system that actually impacts how we treat patients and their experience. As a clinician, research success is when we’ve made a difference in the way we deliver care to patients.

The ultimate success for the RUBY study will be if we can use the information to really transform the way we deliver care to these young women. I am hoping through RUBY, since we are asking these women to give to us, that we can give back to them. The end goal is to improve care for women in Canada with breast cancer.