Charting a New Course in Breast Cancer

Patrick I. Borgen, MD

Patrick I. Borgan, MD, says he feels his life has been uncommonly serendipitous. He has been at the right places at the right times to participate in remarkable events.

In the 1990s, Borgen, now chair of the Department of Surgery at Maimonides Medical Center in Brooklyn, New York, and program chair of the 37th Annual Miami Breast Cancer Conference®, helped clarify the founder’s mutation effect for BRCA mutations. He brought breast cancer treatment to Brooklyn at a time of great unmet need in the borough, and, recognizing the strong link between prescribing practices and the epidemic of opioid abuse, he pursued groundbreaking alternatives to the use of addictive opioids after breast cancer surgery.

His journey to prominence began with relatively humble beginnings. In the mid-1980s he completed his medical degree at the Louisiana State University (LSU) School of Medicine in New Orleans and trained in surgery at the Ochsner Medical Center, historically known as Ochsner Foundation Hospital, in Jefferson, Louisiana.

He had planned to practice in New Orleans but wanted more training. A chance encounter pointed his footsteps north. A friend of a friend connected Borgen with Michael Osborne, MD, MSurg, who was head of the Breast Cancer Research Laboratory at Memorial Sloan Kettering (MSK) Cancer Center in New York, New York.

“I got him on the phone, and I said, ‘Look, you don’t know me, but we have a mutual friend, and I will come work for free.’ And he said, ‘When can you show up?’ ” Working for free in New York was going to require some capital. Borgen took out a $20,000 loan and volunteered at MSK for a year. He left his home in New Orleans and by July of 1989 he was at the epicenter of breast cancer investigation.

It was a gamble, of course, but Borgen was confident it would pay off. “I made one of the rare adult decisions of my life,” he said. “New Orleans had family, it had the culture, the music, the food, the hunting, and the fishing that I grew up with. But MSK offered a world-class laboratory, a world-class research team, thousands and thousands of patients, and a chance to really study breast cancer in a whole different way.

“Looking back, I’m sometimes surprised I was that smart back then because it was a tough decision to leave New Orleans and to leave my family behind. But in retrospect, the richness of my growth, the richness of what I think we accomplished in breast cancer, was remarkable. And that wouldn’t have happened in New Orleans.”

MSK was just as delighted with Borgen. “They decided to keep me. They actually paid me for my second year there, which was nice. And then the following year, I was offered a spot on the breast service. And then 2 years later, I became the chief of the division. It was a very magical time for me.”

After almost 2 decades with MSK, Borgen decided it was time for another life-changing decision. He moved to Maimonides Medical Center to serve as chair of surgery and director of the breast cancer program. The poverty rate is high in Brooklyn—19.8%—and Borgen saw this as an opportunity to expand access to breast cancer treatment to a deeply underserved population.

Miami Breast Cancer Conference^®

As program chair for the 37th Annual Miami Breast Cancer Conference^®, to be held March 5 to 8, 2020, at the Fontainebleau Miami Beach hotel in Florida, Borgen adds heft to an event that has greatly expanded in offerings and relevance over the years. Conference cochairs include renowned investigators Anees B. Chagpar, MD, MPH, MBA, FACS, FRCS(C), a professor of surgery at Yale School of Medicine and assistant director of global oncology at Yale Cancer Center, both in New Haven, Connecticut; Hope S. Rugo, MD, FASCO, professor of medicine and director of Breast Oncology and Clinical Trials Education at the University of California San Francisco, Helen Diller Family Comprehensive Cancer Center; and Debu Tripathy, MD, professor and chair of the Department of Breast Medical Oncology at The University of Texas MD Anderson Cancer Center in Houston.

The conference was more surgery focused when it was founded in the early ’80s. Borgen said it now covers a broad range of disciplines, partly because therapy has evolved into a team approach. Treatment is no longer about the clinical star; it’s about the star team, he said. “Our audience is still about 60% surgeons, but the other 40% is vitally important and rounds out the team,” he explained. “Today it’s impossible to treat this disease without a true multimodal approach.”

The Miami Breast Cancer Conference^® is a natural complement to the San Antonio Breast Cancer Symposium in Texas, Borgen said. Healthcare providers should go to San Antonio to learn about discoveries on the cutting edge of breast cancer care and then go to Miami to learn how to apply those discoveries in practice. “At Miami, we pride ourselves on the practical. Our motto of ‘Hear it Friday, use it Monday’ has never been truer than it is right now,” he said. “This is highly clinically applicable information designed for the practicing surgeon, oncologist, radiation oncologist, radiologist, and pathologist who’s in the trenches diagnosing and treating breast cancer every day.”

This year, the Miami meeting will cover topics including evidence-based alternative medicine, physician burnout, patientcentered care, and treatment de-escalation.

A popular workshop on the art of breaking bad news to patients is back this year. During the training session, a faculty member breaks bad news to an actor playing the part of a patient. The audience then explores what worked, what didn’t, which words were powerful, and which ones clinicians should avoid. Borgen explained that physicians often struggle to communicate unwelcome information to patients.

“This is unbelievably important, especially to our fellows and our trainees,” Borgen said. “I’m really excited about that. I really loved what happened last year with that session.”

The conference also includes many other activities and topics, including world-class tumor board panels, multidisciplinary meetthe- experts small-group breakout sessions, poster talks, contemporary management issues, and real-world outcomes, as well as time for networking in the afternoons.

A Revolution in Breast Cancer Therapy

In his BRCA mutations work, Borgen built on the achievements of investigators before him. One of the forerunners was Mary-Claire King, PhD, a professor of medical genetics and genome sciences at the University of Washington in Seattle, who demonstrated in 1990 that breast cancer is genetically inherited in some families by mapping BRCA1 to chromosome 17q21. Borgen said BRCA mutations revolutionized how investigators thought about breast cancer. He was part of investigative teams that evaluated recurrent BRCA mutations in Ashkenazi Jewish women with breast cancer (Table^1-4). These studies helped clarify the significance of founder’s effect mutations, which are passed down through generations in distinct populations. In one study reported in 1996, Borgen and others estimated that recurrent BRCA1/2 mutations account for >25% of all earlyonset breast cancer cases in Ashkenazi Jewish women with a personal or family history of ovarian cancer.¹

In a second study reported that same year, Borgen and others evaluated the relative risk for developing cancer from mutations in BRCA1 (185delAG) and BRCA2 (6174delT). For the Ashkenazi Jewish population included in the study, the investigators estimated the relative risk of developing breast cancer by age 42 to be 9.3 (CI, 2.5-22.5) for 6174delT compared with 31.0 (CI, 11.0-77.0) for 185delAG. In an analysis of Ashkenazi Jewish women with breast cancer and a family history of breast or ovarian cancer, they calculated a 4-fold greater prevalence of the BRCA1 185delAG mutation compared with the BRCA2 6174delT mutation. They concluded that genetic counseling for Ashkenazi Jewish individuals with these specific germline mutations must be tailored to reflect the risks associated with the mutations.²

Table. Borgen's Contributions to Investigations of BRCA Mutations in Ashkenazi Jewish Individuals (Click to Enlarge)

These studies were the beginning of further investigations that “launched us,” Borgen said. Suddenly, BRCA1 and BRCA2 were of much greater clinical relevance to the world, he said. “You learn genetics in medical school thinking you’ll never use it again, and suddenly it’s part of your day-to-day lexicon.”

As a surgeon, Borgen now conducts a great deal of molecular and genomic research. He noted that even as a young doctor, he felt that surgery wouldn’t be a long-term part of breast cancer care. And even before the BRCA1 mutation was discovered, radical surgery was not considered a feasible preventive option. “The answer had to be medical, it had to be genetic, and it had to be genomic,” he said.

Borgen has been active in investigating male breast cancer throughout his career and recently treated the first recorded case of synchronous bilateral breast cancer in a man. That patient carries the BRCA2 mutation, which is associated with a significantly increased risk for breast cancer.

Clinical trials exploring therapy in men with breast cancer are rare, and male breast cancer is largely treated with the same methods as those for breast cancer in women. Fortunately, Borgen said, men generally respond to the same treatments. The roles of chemotherapy, estrogen blockade with tamoxifen, and radiation are all the same in male patients. “The biggest difference is that 98% of the time, male breast cancers are below the nipple, so we’re doing a lot of mastectomies,” he said. “Breast conservation for men is not nearly as common as it is in female breast cancer.”

Brooklyn’s First Cancer Center

Borgen traded Manhattan for Brooklyn, left MSK, and joined Maimonides in 2006. Although the 2 institutions are about 10 miles apart, they occupy very different places in the world. MSK is the largest and oldest private cancer center in the world and has a history of wealthy and prominent benefactors and extensive cancer investigation. Maimonides treats a patient population that is underserved and largely uninsured. No full-service cancer center existed in Brooklyn, an area of roughly 2.6 million people, until Maimonides established one in 2005. Maimonides now includes Brooklyn’s only fully accredited breast cancer treatment center.

The opportunity to help with the building effort was part of what attracted Borgen to Maimonides. He wanted to serve a different population. “I didn’t grow up in a gilded tower,” he said. “My parents were both happy. They both loved their jobs. And they were both very fulfilled in their jobs. And I knew, having started at Sloan at a very young age, that I really wanted to finish my career going back to an underserved area.”

He considered going back to Louisiana, where the poverty rate is 18.6% compared with 11.8% nationwide, or practicing in Appalachia, notoriously one of the poorest regions in the United States.⁵ “And someone said, ‘Have you ever been to Brooklyn before?’ And I said, ‘Yeah. I’ve been to Peter Luger Steak House twice,’” Borgen said. He did his homework and decided that Brooklyn was the logical next step for him. “I really had a chance to go back to my roots. It was just an unbelievably wonderful opportunity for me,” he added.

Table. Honors and Awards Patrick I. Borgen, MD (Click to Enlarge)

Borgen said Brooklyn is the perfect example of the American melting pot. Maimonides prints its patients’ bill of rights in 43 languages. He said that communicating with a patient sometimes requires an interpreter to translate from, for example, Fukienese to Mandarin and then another to translate from Mandarin to English. “Transmitting complex information is a challenge. It’s also the joy of the job,” he said. “It’s also providing services to a group that 10 years ago didn’t have these services.”

Brooklyn has been hit hard by the opioid crisis, which is why Borgen has made ameliorating this problem part of his mission. Although the number of overdose- related deaths in the borough declined from 2017 to 2018, in the first quarter of 2019, 70 Brooklynites died from opioidrelated overdose.^6,7

Maimonides is an extremely busy medical center, with 120,000 patients visiting the emergency department in 2018. Results from a study of patients showed that the hospital was, unintentionally, a huge source of opioids in the area. Many patients with opioid-related problems passed through the emergency department every day, Borgen said. “The study showed that four-fifths of those addicts and victims of overdose started with an MD-prescribed narcotic,” he said.

Borgen has also made it his mission to eliminate the use of opioids for surgical pain. Under his direction, Maimonides has been a leader in Enhanced Recovery after Surgery (ERAS) research. In October 2019, a group from Maimonides published findings from an evaluation of a 10-step protocol in which patients undergoing mastectomy were assigned to multimodal analgesia to decrease the number of opioids prescribed at discharge.

From 2017 to 2018, a total of 153 patients underwent mastectomy and 57 were eligible for this study. Twenty patients were assigned to ERAS, and 37 received standard care. Investigators found that the ERAS cohort received 2.0 (range, 0-40.0) oral morphine equivalents at discharge compared with 59.8 (0-120.0) for the standard-care group (P <.001).⁸ Thirteen patients (65%) did not require any opioids while hospitalized, and 19 (95%) were discharged without an opioid prescription. Patients in the ERAS protocol also reported significantly lower postoperative pain scores on day 1 after surgery (3.1 vs 5.5) and at 1 week after surgery (1.8 vs 5.8).

“I’m really happy with what we did in Brooklyn. We’ve now treated more than 1000 consecutive patients using a breast-conserving approach without a single milligram of opioids,” Borgen said. “If the rest of the country could come close to that, we could really make a dent in the opioid epidemic in this country.”

“I Wanted to Make a Difference”

Borgen is the son of a genuine rocket scientist and an elementary school teacher. His father was part of the team that built the first stage of the Apollo Saturn V rocket, and Borgen very much wanted to follow in his footsteps. He studied engineering as an undergraduate at Tulane University in New Orleans but found his heart just wasn’t in it.

“Engineering is a lonely sport. Back then, computers were new, but it was a lot of drafting, a lot of computer work, a lot of very high-powered mathematics, and very little socialization,” Borgen said. “I loved the science of it, and I certainly thought that if the government would have continued the space program, it would have been an exciting place to continue. But it didn’t have the human interaction that medicine had.

“At the end of my engineering degree at Tulane, I applied for medical school, and lo and behold, I got into LSU Medical School, and I’ve never looked back. I’ve always been extremely happy about my decision to pursue medicine,” he said.

Borgen worked as a trauma surgeon during his residency, which was exciting but not intellectually stimulating. He wanted to be able to do a deep dive into a common disease that was poorly understood. In the late ’80s, that meant breast cancer.

“We were still doing radical and modified radical mastectomies. A quarter of our patients were dying,” Borgen said. “There were huge [adverse] effects from the surgery; it was debilitating and disfiguring and defeminizing. Once I decided on surgical oncology, the choice for breast cancer for me was easy. It was the most interesting, least well understood disease that was out there.”

Borgen noted that being part of an intervention at a critical moment in another human’s life attracted him to medicine. “I wanted to make a difference,” he said. Plus, he loves working with patients.

Borgen credits his mentor, Sir Murray F. Brennan, GNZM, MD, FACS, with making him a successful breast cancer surgeon. Brennan, now senior vice president of international programs and the Benno C. Schmidt Chair in Clinical Oncology at MSK, maintained a pitiless philosophy of endless self-criticism. His motto was “Adulation is soporific.”

Borgen has boundless respect for Brennan, calling him the greatest cancer surgeon of the 20th century. Today the 2 men are close, and Borgen isn’t afraid to upbraid his mentor from time to time. “I laugh now when I think about Dr Brennan and the wonderful impression that he made on me. But it would have been nice every once in a while to hear ‘Attaboy!’”

Kinder, Gentler Approaches

Borgen always admired that his mother made a difference in the lives of her students, and his current role allows him to combine his mother’s love of teaching with his father’s technical prowess. Maimonides employs more than 500 residents and interns, including more than 50 in surgery, and Borgen enjoys working closely with junior physicians as a teacher and a mentor. “We’ve got a large residency program here in Brooklyn, and it’s one of my favorite parts of the job,” he said. “We have a breast fellow position, and I love teaching the next generation of breast surgeons. So teaching is still a big part of what I love to do.”

Borgen also gets to hire the physicians he works with and looks for a particular personality. In the past, he put a premium on academic productivity. Now he’s looking for surgeons who are compassionate as well as talented.

“I matured and realized that smart was relatively easy; nice was not always so easy,” Borgen said. “As I was building my team here in Brooklyn, we recruited for values, emotional IQ, and empathy first—then we looked at somebody’s credentials.”

Borgen has put together the kind of team he wants and created a place where physicians want to practice. He has hired about 80 surgeons at Maimonides and says he regularly gets calls from physicians who are drawn to the “kinder and gentler” work environment. It’s rare to find a hospital that provides good care while making the patient feel cared for.

“We’ve created a work environment that’s very different than most academic institutions. There’s camaraderie, there’s collegiality, there’s mutual support, there’s professionalism, there’s transparency,” Borgen said. “People are self-critical. We have our morbidity and mortality conferences, and the first thing the surgeon says is, ‘Let me tell you what I did and what I would do different next time,’ and that makes all the difference.

“Surgeons have a bad reputation of being [jerks], and sometimes it’s true. And we don’t think surgeons need to be. The surgeon in breast cancer is often the quarterback of the team and needs to be kind and gentle and really smart and really empathetic, and I think that’s what we’re achieving.”

He admits that he’s no longer the “tough SOB” he used to be. Borgen demands excellence, but he’s more willing to offer praise. “This new generation of what have been called millennials who are coming into medicine are wonderful,” he said. “But the truth is they respond really well to positive reinforcement, more so than my generation did. I’ve had to change my style to fit the new generation of cancer surgeons and cancer researchers, and I’m very comfortable in that.”

References

1. Neuhausen S, Gilewski T, Norton L, et al. Recurrent BRCA2 6174delT mutations in Ashkenazi Jewish women affected by breast cancer. Nat Genet. 1996;13(1):126-128. doi: 10.1038/ng0596-126.
2. Oddoux C, Struewing JP, Clayton CM, et al. The carrier frequency of the BRCA2 617delT mutation among Ashkenazi Jewish individuals is approximately 1%. Nat Genet. 1996;14(2):188-190. doi: 10.1038/ng1096-188.
3. Robson M, Gilewski T, Haas B, et al. BRCA-associated breast cancer in young women. J Clin Oncol. 1998;16(5):1642-1649. doi: 10.1200/JCO.1998.16.5.1642.
4. Robson M, Levin D, Federici M, et al. Breast conservation therapy for invasive breast cancer in Ashkenazi women with BRCA gene founder mutations. J Natl Cancer Inst. 1999;91(24):2112-2117. doi: 10.1093/jnci/91.24.2112.
5. Quick facts: Louisiana. US Census Bureau website. bit.ly/36tu9i3. Accessed December 4, 2019.
6. Health department announces drug overdose deaths decreased in 2018 for the first time in eight years following historic investments [news release]. New York, NY: New York City Department of Health and Mental Hygiene; August 26, 2019. on.nyc.gov/2Lyegib. Accessed December 16, 2019.
7. Unintentional drug poisoning (overdose) deaths: quarter 1, 2019, New York City. City of New York website. www1.nyc.gov/assets/doh/downloads/pdf/basas/provisional-overdose-report-first-quarter-2019.pdf. Published August 2019. Accessed December 13, 2019.
8. Rojas KE, Fortes TA, Flom PL, Manasseh DM, Andaz C, Borgen PI. Mastectomy is no longer an indication for postoperative opioid prescription at discharge. Am J Surg. 2019;218(4):700-705. doi: 10.1016/j.amjsurg.2019.07.017.