Kathryn J. Ruddy, MD, MPH, has always wanted to be of service. It's no surprise to family and friends that her generous spirit led to a career helping those with cancer contend with stresses inherent in being patients. As such, she is now Director of Cancer Survivorship and Associate Professor of Oncology at Mayo Clinic College of Medicine, Rochester, Minn.
During her childhood in Princeton, N.J., Ruddy developed her passion for service. "I volunteered to do all sorts of things-serving food at soup kitchens, packing supplies for the homeless, running errands for nursing home residents, working with Habitat for Humanity.
Daughter to a nephrologist (father) and a psychology professor (mother), Ruddy was exposed to medicine and science early on and suspected she wanted to be a doctor as she headed to Harvard for undergraduate studies. "I always loved science and biology, and there was that calling to help others-medicine fit well with all of that."
As a second-year medical student at the University of Pennsylvania, Philadelphia, one of her closest friends was diagnosed with acute myeloid leukemia. "It was a complete shock. Thankfully, she had a very good prognosis, but I suddenly realized how frightening and difficult the side effects of cancer treatment can be, including the risk of infertility in young patients, and I became interested in a career in oncology to learn to minimize these toxicities."
Ruddy went on to do an internal medicine residency at Massachusetts General Hospital in Boston. There, she met her husband, now a cardiologist at Mayo. She stayed in Boston for a combined fellowship in medical oncology and hematology at Mass General and Dana-Farber Cancer Institute, where she remained on staff for 4 years before assuming her position at Mayo Clinic in 2013.
"While in Boston, I met Ann Partridge, MD, MPH, whose phenomenal research on survivor issues, including fertility in breast cancer, inspired me to become a breast oncologist and a survivorship researcher with a focus on premenopausal breast cancer. Subsequently, I also developed specific interests in male breast cancer, symptom intervention, and patient-reported outcomes," explained Ruddy.
Combining Clinical Practice & Research
Today her position at Mayo allows Ruddy what she considers "the honor and privilege of caring for people in need" through her oncology practice. "I cherish my relationships with my patients, and I try my best to understand how they feel and what they most need from me emotionally as well as medically. Oncology is not just about giving chemotherapy; it's about caring for the whole person."
It is that viewpoint that underlies Ruddy's research focused on survivorship and how therapeutic treatments can impact people. She recently received a National Comprehensive Cancer Network (NCCN) grant to look at patterns of care in survivorship and identify gaps where care could be improved to meet patients' needs.
"We know cancer and cancer treatments can cause some very long-term psychological and physical problems that can include nerve damage, cognitive problems, even psychological problems like anxiety and depression. My overarching research goal is to improve our ability to predict, prevent, and treat the toxicities of oncologic therapy," Ruddy explained. "I'm especially trying to determine how we can predict who is going to lose fertility after specific cancer treatments so that we can better inform decisions about fertility preservation techniques.
"These patients are facing something that is potentially doubly traumatic-physically because of the menopausal symptoms that often occur due to loss of ovarian function, and emotionally if they were hoping to have additional biological children in the future."
As to who may be at greater risk for infertility, Ruddy said all of the answers are not yet known. However, there appear to be "... genetic components," she answered. "At Mayo, I am working with phenomenal genetic epidemiologists to gather samples and patient-reported data to study this issue. We hope to find a blood-based biomarker that we can use to better inform women about their likelihood of losing ovarian function if they take one treatment type versus another, and about the potential benefit of using a fertility preservation strategy such as egg harvesting and freezing."
Moving Forward
Some therapies are more likely to impact fertility than others, but these issues are not well studied in newer drugs. "We must understand how new therapies fit into the puzzle," Ruddy stressed. While new therapies are tested for safety and efficacy before they are approved by the FDA, they are not traditionally tested for fertility impact, she noted.
"I am trying to incorporate an assessment of gonadal toxicity into more of our studies. At the Translational Breast Cancer Research Consortium, we've been talking about a more uniformed way to look at impact of therapies on a variety of patient-reported outcomes," she said. "Fertility is not the only inadequately addressed survivor issue. Nerve damage causing sometimes permanent peripheral neuropathy can be a lifelong major problem, and this can be caused by a lot of chemotherapies used for a lot of different cancers. Chemotherapy-induced peripheral neuropathy can leave patients with chronic pain, numbness, and/or tingling, impairing quality of life and restricting activities of daily living."
Ruddy said one major focus of ongoing survivorship research is to find drugs or other techniques to help prevent or treat neuropathy. While preventive drug treatments have not been very promising to date, "I have been working with Dr. Charles Loprinzi and others to figure out if cooling the hands and feet during treatment to prevent chemotherapy delivery to the fingers or toes will help prevent neuropathy. This is similar to scalp cooling for hair retention or chewing ice to prevent mouth sores during chemotherapy," said Ruddy. "Neuropathy prevention is particularly important because nerve damage can be long-lasting, whereas hair loss and mouth sores generally resolve after chemo finishes."
Asked to characterize how her research is carried out, Ruddy said it is conducted with clinical patients and by using administrative claims data.
"To study most issues related to symptoms and fertility, we get the data directly from patient," she said. "In the Mayo Breast Disease Registry, we have enrolled nearly 7,000 women with breast cancer who have been cared for at Mayo, and we are now following them over time to learn more about toxicities and predictors of treatment response, including patterns of recurrence."
Her work through the NCCN grant uses administrative claims data to explore guideline adherence in breast cancer survivors. "This work primarily assesses the health care system and care providers," Ruddy explained. "Are we ordering what the guidelines recommend for our patients in terms of breast imaging? Are we seeing patients at the recommended frequency, and are we assuring that they have the tests they need to follow their bone health and cardiac function? Claims data are valuable in that they provide a broad view of what is happening across the country, not just at a single institution or a small group of institutions. We can assess patterns of treatment and regional differences visit frequency, and we can look at what types of treatments are being given."
Patient preferences, values, and choices are also in the crosshairs of her research. "We are about to look at endocrine therapy and what factors across the country impact whether or not patients stop taking their recommended adjuvant endocrine therapies," she detailed. "Pills are usually recommended to be taken for 5-10 years, but some studies have shown many patients stop early or do not take them as recommended, sometimes due to toxicity. With administrative claims data, we have claims for both treatments received in the clinic and prescription fills, so we can look at what types of medications patients are taking at home."
Some of the early findings from this work are expected to be published this spring in the Journal of the National Comprehensive Cancer Network, revealing gaps in breast surveillance imaging, particularly later. "Mammography rates fall off over time after treatment is completed," Ruddy noted. "It will be important to study how modifiable provider-related issues such as notification systems and outreach can improve adherence with guidelines in this setting."
Considering Breast Cancer in Men
Ruddy is also co-leading a quality-of-life survey component of a joint international effort to study men's breast cancer.
"We have prospectively enrolled hundreds of patients internationally to investigate treatments received, responses to treatments, toxicities, and blood-based biomarkers. We hope this will inform the future development of a clinical trial focused on male breast cancer patients," said Ruddy. "We also hope data from this prospective cohort will help us understand how breast cancer impacts quality of life in men."
Ruddy explained that breast cancer is much rarer in men (just 1% of all breast cancers occur in males). The prognosis in men appears to be approximately the same as for female patients if it is caught just as early. However, because men are not having mammograms, their cancers are often detected at a later stage and often already have spread to axillary nodes.
"And men may not have the same threshold of concern that women have if they find a breast abnormality," Ruddy said. "Care providers need to be aware of the possibility that a breast change in a male could be cancer. We hope to increase awareness of this so men can get evaluated and treated earlier."
Personal Priorities
In those rare hours when Ruddy is not chest high in patients and research, she enjoys life with her husband and their three young children. She laughs at the idea of "hobbies," saying that taking care of the little ones and spending time with friends and family are all-encompassing. There are rounds of board games, card games, ping pong, and watching football with her son; and gymnastics, drawing, costumes, and baby dolls with her daughters. Personal indulgences are reading and traveling.
When it comes to the hopes she holds for her career, Ruddy said, "While I would love to completely eliminate toxicities from cancer therapies, I more realistically aim to predict what toxicities a given patient will experience from a given regimen, pinpoint a time frame for recovery, and identify interventions that will mitigate symptom burden. That would improve our ability to tailor cancer treatments and offer an improved quality of life."
As for the here and now, she stressed, "With so many exciting new drugs entering clinical practice and improving our ability to control and cure cancers, we need to do more during and after treatment to predict, prevent, and treat their toxicities."
Valerie Neff Newitt is a contributing writer.