Dr. Harutyunyan has made significant contributions to research and patient care throughout his career. He has worked as a clinical researcher at the “City of Smile” Charitable Foundation and as a medical coordinator at the Union of Armenian Doctors.
Dr. Harutyunyan’s played a key role in the launch of a Palliative Medicine Service at Yeolyan Hematology and Oncology Center.
Martin Harutyunyan: Greetings and a warm welcome to Oncology. Today we have the honour of hosting Professor Etienne Brain, a highly respected medical oncologist at Institutes Curie in Paris and St Claude. He is well known for his extensive research in breast cancer and geriatric oncology.
We first met at the Oncology Academy meeting in Lisbon in 2023 after trying to schedule this interview multiple times. It’s finally happening. Interestingly, I wanted to interview him during this year’s mask meeting as well, but unfortunately our schedules only matched up just as I was at the airport heading home.
My name is Martin Harutyunyan. and I’m a medical oncologist and palliative care specialist based in Yerevan, Armenia. It’s a pleasure to be hosting this special interview on OncoDaily. Hi, Professor Brain.
We are glad to have you with us today.
Etienne Brain: Good afternoon.
Martin Harutyunyan: Let’s start at the beginning. What initially drew you to the field of oncology and what motivated your focus on breast cancer and geriatric oncology?
Etienne Brain: I think that was the first point was that I realised very early, almost 25 years ago, that the amount of the literature or robust data related to how to care and to organise treatments of older women with breast cancer was limited in the literature. And so we were short of robust data. And it led me to investigate and to study a bit further the representation of these patients in most clinical trials related to the topic.
And that’s how things started, because I realised that the amount of knowledge was limited and that we didn’t have very serious guidelines.
Martin Harutyunyan: Thank you. You have had a remarkable journey with the EORTC Breast Cancer Group. Could you share some insights from your recent role and how it has influenced breast cancer treatment strategies?
Etienne Brain: I think the main point that I tried to do while chairing the group of breast cancer at EORTC was really to push the ideas that we needed to develop on to support more research for the major population of patients with breast cancer currently, which is actually the population of older ones. You know that 30% of breast cancer occur after 65, after 70, and almost 40% if you start with a threshold of 65. Very ironically, these represent very often less than 10%.
And if you address the question above 70 or 75, it’s less than 3 to 4% of enrolled patients in specific research programmes. So, all that was a very determinant in the way I wanted to push and to help developing specific research to match a bit better the reality and to reduce the gap of knowledge. That’s what I’ve done for almost 10 years at EORTC.
Martin Harutyunyan: Treating older cancer patients comes with unique challenges. How do you approach adjusting treatment strategies for this demographic? And what are the key considerations?
Etienne Brain: I think as it is almost rather impossible to treat or to define the strategy for a specific cancer without a TNM or without the biology of phenotype for any tumour type. It has become also very clear that the treatment of somebody above a certain age should incorporate or include some good picture of the level of health, the health status of the patient.
In order to capture what is very common in the older ones, it’s the increasing frailty, the increase of frailty according to age, which comes with ageing and which makes that after 70 to 75, up to 30% of these patients present spontaneously with some defects on frailty scales.
And for the rest, if you take old comers in metastatic setting, it can reach up to 70% of them from the age of 70. And for early stages, it’s roughly between 40 and 50%. So the word behind, which speak for all these numbers speak for themselves, but it means that behind you need to learn to adjust or nuance the treatment intensity, according to, of course, the biology of cancer, but also these frailty components.
And if you do not so, you take risk and you jeopardize most of the benefits that you seek to provide with your treatment. So that’s this leitmotif that you get when you treat older ones, which is adjustments are constant or very frequent in your management.
Martin Harutyunyan: Thank you. The field of breast cancer treatment has seen many advancements. Which ones over the past decade do you find most promising and how have they impacted patient care?
Etienne Brain: You mean for breast? Of course. I think one of the two main aspects that I see are as a one making a underpinning or stressing the importance of immune aspects and the introduction of immunotherapy or it is a bit like the return of immunotherapy, which also was part of the strategies investigated in the 80s, but differently.
Now with the discovery of these antibodies able to stimulate the internal defence, the inmates and the acquired immune defence, I think things have changed a lot. And so the introduction of this component, the treatment is very important. The second point for me also is really the precision medicine that has been introduced with the specific targets like HER2, the PIVOT HER2, but also the genetic alterations.
And behind that, it has produced many possibilities to decrease or to deescalate the intensity of treatment applied a bit blindly or with less guidance that we used to do until the middle of 2010, 2020. So that was a big, big step. It’s all that came together.
Precision, precision, sorry, and counting on the own defence and capacity of patients to defend themselves and at the same time deescalating what creates the most concerning issues in terms of sequelae or long-term effects, long-term side effects.
Martin Harutyunyan: Thank you. Continuing this topic, personalised medicine is a growing field. How do you see its future in oncology, especially regarding geriatric patients?
Etienne Brain: Well, as I said previously, I think the personalisation of treatment for older ones really relies on the true and balanced consideration and fair consideration of the two aspects, the tumour and the patient. So it means that we need progressively, and it has been the case for the past 10 years, we need to learn how to implement this geriatric assessment and this assessment of frailty in defining the intensity of the treatment we’re going to apply with all the precision tools that we have for the tumour. So we cannot duck.
I think we can have a very artificial decision or discussion if we do not consider both aspects in the right way. And we have many examples, especially for breast, that taking this into account leads to important differences of treatment decisions and also in terms of benefit provided.
And there is a high level of evidence currently, which has been developed for the past one decade, probably, with large-scale trials demonstrating the high value of this strategy, implementing this assessment to correct or to adjust with very often decrease of intensity, but no loss of efficacy and no loss of impact on the disease.
That’s very important. At the same time, decreasing the side effects rates, improving quality of life, improving communication with patients. And so all these aspects which make the challenge of treating sometimes difficult disease much easier in older ones.
Martin Harutyunyan: Thank you. You have been recognised with several significant honours, such as the B.J. Kennedy Geriatric Oncology Award in 2022. How have these acknowledgements influenced your career and research focus?
Etienne Brain: It has certainly amplified my wish to really stick closer to what is the right question, the right design to investigate. And that means behind that is increased my interest in the participative research that we need to develop with this population. And again, with the global goal to restore a kind of fair balance in terms of what is developed in general oncology, which has some often left behind the older ones, while they represent very soon in the coming years, they should become more than half percent, half 50 percent of the population treated.
And they are not so far from this threshold. And they should be better. They deserve much better attention.
So moving the lines is important and taking this social determinants in the way we handle research, we develop it, how we choose the right endpoints, what is meaningful, clinically meaningful, but also meaningful to older ones is important.
Martin Harutyunyan: Your contributions to the International Society of Geriatric Oncology have helped shape global cancer care standards. Can you discuss the significance of your work with SIOG and its impact on the field?
Etienne Brain: I guess that SIOG has a long history. It has been created almost 25 years ago with a very important impulse from Europe. But not only U.S., of course, America was on board. But I mean, the Italy, France were very determined in the launch of the organization and how to progressively combine or make geriatrics and oncology work better together.
So I think SIOG has been instrumentally developing education for this, educating young generation to this open openness for really balancing these two important fields for the best to our patients. So that means behind bringing together geriatricians and oncologists to work better for this definition.
So SIOG has initiated many actions like the development of specific guidelines in relation or in collaboration with key society like ESMO or like ASCO. And every time with a great role in terms of as being the catalyst for pushing the need, pushing to reach out really concrete actions and publications. And all that has been very instrumental.
Education, implementing a geriatric assessment in practice and making it also international, because it is challenging for everyone and we meet almost the same challenges anywhere. There is no difference between Europe or Asia, for example, or Latin America. I think we meet the same challenges in terms of epidemiology.
Martin Harutyunyan: Aspiring oncologists look up to leaders like you. What advice would you give to young professionals who aspire to make meaningful contributions to oncology?
Etienne Brain: I think that there is certainly a field which is very dear to me. It is really to try to assuage or decrease these gaps which exist and to stick a bit more to reality, to get skewed images of practice. That means to make a focus on pragmatic ideas in terms of research and also becoming more aware that actually the service that you can give to the population for older ones, because they represent so many patients, can be very high while there is a much higher competition in many subcategories of population in many fields.
What I mean behind is that you can revisit many concepts and question the validity of these concepts as they have been developed in younger ones, in younger adults, but there is a whole field of application where you can, again, with less competition, with a lot of room to raise right questions and adequate ones for the older ones. That is certainly a topic, a field which is not virgin. There are many people working on it, but probably easier to address, especially when you start your career.
Martin Harutyunyan: Thank you. With numerous leadership roles and clinical commitments, how do you balance your professional responsibilities with your personal life and what strategies have helped you manage this effectively?
Etienne Brain: Well, that’s always a very personal question. I mean, how you manage this balance and your commitments to your family life and private life. I mean, certainly you need to find some limits because if you cannot set limits, then your time is eaten up so easily.
You need to have also, you need to keep some insight or not distance, but insight to realize that medicine probably and science as it limits, it evolves slowly. Sometimes you have the impression that you make great strides, but the application and how the consequences of the impact occur, sometimes or very often it takes much more time than what you think. So, always have this insight and realize that the other dimensions which are related to your own life is really important.
How you interact with others. Personally, I have a lot of implications in music. For example, I’ve been singing, playing the flute, playing in a small chamber orchestra and part of a lyrical company and choir.
So, the World Doctors Orchestra is part of my activity, for example. So, that keeps me with a lot of energy, I would say.
Martin Harutyunyan: Thank you, Professor Brain, for your insights today and thanks to our listeners for joining us. Keep up with the Rhythm of Oncology on OncoDaily. Take care and goodbye.
