Breast cancer specialist Brittany L. Bychkovsky, MD, MSc, grew up primarily in Kansas; however, given that her father was a pilot, her childhood was not wholly centered in the Sunflower State. “When I was 12 years old, my mom, who was a schoolteacher, was diagnosed with stage III breast cancer. Her diagnosis came after we had been abroad for 2 years in Malaysia and had been in a different health-care system. When we returned to Kansas, my mom was diagnosed, and it was scary since my aunt had died of metastatic breast cancer. So, although cancer is in my family, no one has a known cancer gene, and this fact has likely influenced my career path,” she explained.
Dr. Bychkovsky continued: “My mother had aggressive treatment for her breast cancer. She participated in a SWOG clinical trial, where she received an autologous stem cell transplant. We do not do transplants for breast cancer anymore, as it likely represents overtreatment in most of our patients with cancer. Thankfully, my mom was cured of her disease and is currently a long-term breast cancer survivor. However, given the period of her therapy, she may have had more treatment than was necessary for cure. She received a lot of chemotherapy, which accelerated bone loss and likely affects her strength, even today.”
An Older Sister Serves as a Mentor
After the experience with her mother’s cancer challenge, Dr. Bychkovsky’s older sister, Larissa Lee, MD, decided she wanted to pursue a career in medicine. “My sister was the first in our family to be a doctor. Until then, in fact, no one had previously worked in the health-care sector. Although my sister announced her goal to become a doctor while in high school, I was reluctant to decide on what I wanted to do. I really liked science and math but didn’t choose medicine until after I had completed my undergraduate degree,” she shared.
“I was of the generation of Harvard Medical School students who had the fortunate experience to be inspired by the late Dr. Paul Farmer.”— Brittany L. Bychkovsky, MD, MSc
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After graduating from high school, Dr. Bychkovsky entered the University of Kansas as a chemistry major. “I’m a Jayhawk, and although I majored in chemistry, I wasn’t sure if I wanted to become an archaeologist, chemist, environmental scientist, or doctor. So, after graduation, I went to Peru for 3 months and volunteered with an archaeo-logic project at Puruchuco. This was not an established exchange; I’d simply e-mailed National Geographic and asked to be put in contact with the project lead, who was Guillermo “Willy” Cock, and he said I could come and help. Willy Cock, a well-known archaeologist, picked me up at 4:00 AM at the airport in Lima, and that was the start of my summer. For the record, I had also contacted many hospitals and health-care organizations asking to volunteer, and most were looking for volunteers with medical skills or wanted me to pay for the experience, and my funding was limited!”
During her trip, Dr. Bychkovsky stayed with a renowned archeologist named Elena Goycochea Diaz and her family. “Elena was a second mom to me. Her mother had breast cancer and lived in Trujillo, which is in the northern part of Peru. I remember traveling for 2 hours by bus with Elena across Lima to go to a public pharmacy to buy tamoxifen and mail it to her mother in Trujillo. Although it was an inefficient way to distribute an essential medicine within a country, I remember the price for a 90-day supply was like $3 compared to what my mom was paying in Kansas, which was $20 per month out of pocket,” said Dr. Bychkovsky. “At the end of my stay in Peru, I remember asking Elena if she thought I should become an archaeologist or a doctor? She said immediately that if I wanted to have more impact on people’s lives, I should go to medical school and become a doctor. So, that’s what I did.”
Another Valuable Trip Abroad
After returning from her volunteer work in Peru, Dr. Bychkovsky spent 2 years in Germany, where she completed her MS at the Ruprecht-Karls Universität Heidelberg, one of the oldest universities in the world. “I worked in a lab with Professor Luise Krauth-Siegel and Dr. Heiner Schirmer, who were involved in rational drug design for trypanosomiasis. This experience was foundational to my understanding drug development and targeted therapies as a clinician in academics,” said Dr. Bychkovsky.
After attaining her MSc, Dr. Bychkovsky entered Harvard Medical School in 2004. “When I started medical school, I continued to be interested in research and completed my training in the Health Sciences and Technology Program, which is a joint program between MIT and Harvard Medical School. This training was exceptional, emphasizing the importance of translational research, and many of my classmates are now physician-scientists. In hindsight, at the start of medical school, I was interested in breast oncology and cancer genetics, but during medical school, I was also drawn to infectious disease and global health work. I was of the generation of Harvard Medical School students who had the fortunate experience to be inspired by the late Dr. Paul Farmer,” said Dr. Bychkovsky.
Good Advice From a Valued Mentor
After medical school, Dr. Bychkovsky stayed in Boston for residency training at Massachusetts General Hospital, and it was there that she met Professor Paul Goss. “Paul Goss is a well-known breast oncologist originally from South Africa who led many of the early breast cancer prevention trials; when I met him, he was passionate about global oncology and training physicians around the world in clinical research. He was an early mentor to me and influenced my career trajectory,” she shared.
Dr. Bychkovsky recalled planning to do a medical rotation in South Africa to learn more about HIV/AIDs care. “When I told Paul, he suggested I go somewhere instead where I’d see patients with cancer on clinical trials, such as Brazil. He even reached out to his associate Dr. Carlos Barrios in Porto Alegre, who at the time was developing a cancer trial network in Latin America, and got me a position there. The experience was wonderful, and it truly influenced my perspective on cancer care worldwide.”
“In the future, we will be able to do additional testing in a patient with a cancer gene mutation to aid in risk assessment.”— Brittany L. Bychkovsky, MD, MSc
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Dr. Bychkovsky remembered how motivated Dr. Barrios and his team were at the time to enroll patients with HER2-positive breast cancer on trials, since at that time, patients who received care in the public sector did not have access to trastuzumab. “This was in 2007, and it meant that clinical trial enrollment provided access to a therapy that had been standard of care in the United States since 1998. I still think today about how we can overcome barriers to new treatments for patients with cancer worldwide,” commented Dr. Bychkovsky. “While there, I started writing a review article on breast cancer control in Brazil, which was published in The Lancet Oncology and prompted advocacy for better cancer care in Latin America, China, India, and Russia.”
A Passion for Cancer Genetics
After her fellowship training, Dr. Bychkovsky started on staff at Dana-Farber Cancer Institute (DFCI) in breast oncology. “Over the past few years, I have become more involved in cancer genetics, both clinically and in my research. Dr. Judy Garber has been an outstanding clinical and research mentor in recent years; I go to her with my hard clinical and research questions. I have also learned so much from Dr. Huma Rana, who is a geneticist and has a different perspective and training than my background. I continue to learn from Dr. Garber and Dr. Rana, and we have a handful of ongoing projects,” she said.
Building a Global Cancer Community
Asked about her work in global oncology, Dr. Bychkovsky replied: “I am still involved in the Global Cancer Institute, founded by Dr. Goss. This group is currently led by Dr. Don Dizon and Dr. Ben Ho Park, and we have a monthly tumor board with physicians from around the world to review breast and gynecologic cancer cases. As part of this tumor board, we are often asking for germline genetic testing to be performed. Although the cost of this testing has come down and the capacity to do it has grown, it is still unavailable to many patients around the world.
Dr. Bychkovsky continued: “Our awareness of this issue prompted our group to advocate for germline cancer genetic testing to be included on the Essential Diagnostics List of the World Health Organization, and this was published in The Lancet Oncology. We also collaborated with Dr. Renata Sandoval, a geneticist from Brazil who is at DFCI on a research exchange, and her insight was valuable to this effort. Furthermore, cancer genetic testing affects survivorship care. If a woman has an early diagnosis of triple-negative breast cancer in her early 30s, she may receive definitive therapy and be cured. However, if she has BRCA1 and doesn’t know it, she may then develop ovarian cancer in her 40s. Without cancer genetic testing, we are missing the opportunity to avoid the ovarian cancer diagnosis.”
A Closing Thought
Dr. Bychkovsky offered a closing thought on the state of cancer genetics moving forward: “Cancer genetics is still a young field, and we have a lot more to learn. We are still characterizing the cancer risks with certain genes. For example, with Nihat Agaoglu, a medical geneticist in Turkey; Dr. Rana; and Dr. Garber, we have been collaborating with Ambry Genetics to refine the cancer phenotype that is associated with pathogenic variants in CHEK2. One thing that has emerged in the literature on CHEK2 is that there are high-risk variants, such as 1100delC, and lower-risk variants, such as I157T, and we want to better understand these classifications and cancer risk.1 An individual cancer gene mutation is rare, but with larger cohorts, we will better understand the association and risk with cancer.”
According to Dr. Bychkovsky, now that more people are being tested, pathogenic variants are being identified in individuals who do not have a personal or family history of cancer. “In the future, we will be able to do additional testing in a patient with a cancer gene mutation to aid in risk assessment. It would be informative to care if we could tell a patient with BRCA in her 20s that she has a high risk of breast cancer with this pathogenic variant and certain genetic modifiers or a lower risk than the average patient with BRCA; in the latter case, we could delay screening and risk--reducing mastectomy until later in life.”
Finally, Dr. Bychkovsky noted the need for new screening algorithms for patients with cancer. “The field is advancing, and for patients with a hereditary risk for pancreatic cancer, we are now offering screening; but we do not have established screening protocols for all cancer types. There’s a lot of work ahead, and I’m very excited to be part of the new and emerging world of oncology, here and around the globe.”
DISCLOSURE: Dr. Bychkovsky reported no conflicts of interest.
Reference
1. Bychkovsky BL, Agaoglu NB, Horton C, et al: Differences in cancer phenotypes among frequent CHEK2 variants and implications for clinical care—checking CHEK2. JAMA Oncol 8:1598-1606, 2022.
