From prevention and detection to treatment and reconstruction, the latest data and technological advancements bring more hope to patients affected by breast cancer.
Sometimes the simple things make the biggest difference – even in breast cancer prevention.
Now, recent data reinforces the importance of healthy lifestyle choices in reducing the risk of breast cancer development, explains Edith A. Perez, M.D., medical oncologist and director of the Mayo Center’s Breast Clinic. Moreover, the latest studies reveal that regular exercise and a healthy weight also lower the risk of cancer recurrence.
“We need to concentrate more on lifestyle issues,” Dr. Perez says. “It needs to be part of our day-to-day recommendations for patients.”
Though the chemical explanation for the connection to breast cancer prevention is still somewhat elusive, Dr. Perez notes that changes in insulin resistance and estrogen levels resulting from physical activity and proper caloric intake may affect the relationship.
“We continue looking for new medications to decrease the risk, but this is something we can all do,” she says.
And as studies investigate the effects of newer drugs in advanced stages of breast cancer, it’ll only be a year or two until these drugs can be evaluated in prevention studies, too, Dr. Perez says.
Diving into Detection
While mammograms remain the standard for screening, breast MRIs are playing an evermore important role in the detection process, Dr. Perez says. Actually, she elaborates, patients with at least a 15 to 20 percent increased risk of developing breast cancer should be screened with the breast MRI rather than a clinical evaluation and mammogram. Though particularly beneficial for patients with a strong family history of breast cancer, an identified genetic mutation that exposes them to breast cancer development, and women with dense breasts, Dr. Perez strongly cautions against using the MRI as a screening tool for all patients.
“It’s good to have the option of a sensitive test,” she says, “but we don’t want to go overboard.”
Beyond enhanced screening, the breast MRI is also helpful when working with patients already diagnosed with invasive breast cancer. Its pristine visibility helps identify the best surgical procedure and, if a mammogram detects cancer on one breast, the bilateral MRI may also detect a lesion in the other breast; in three percent of patients, Dr. Perez says, the MRI finds cancer in both breasts.
But even with advancements in screening and detection, Shahla Masood, M.D., emphasizes the importance of a second opinion. Dr. Masood, Professor and Chair of the Department of Pathology at the University of Florida College of Medicine – Jacksonville, Chief of Pathology and Laboratory Medicine at Shands Jacksonville, Director of the University of Florida Outreach Library, Editor-in-Chief of The Breast Journal, and President of the World Society of Breast Health, explains that, while a very small number of breast cancers are misdiagnosed, the many look-alikes in breast pathology may lead to under- or over-diagnosis.
“Breast cancer is a heterogeneous disease with a variety of forms and shapes,” she says. “The treatment, the response to therapy … it’s all related to the type of breast cancer.”
Additionally, evolutions in technology, molecularlogy and sub-classifications of breast cancer lead to a better understanding of individual tumors, Dr. Masood explains, which impacts the diagnosis and recommended therapy options.
Tackling the Treatment
It’s not just prevention and detection that have come a long way. Linda Sylvester, M.D., FACP, medical oncologist with Florida Oncology Associates and Co-Founder of the Pink Ribbon Foundation, explains that personalized treatment options are also positively affecting patient outcomes.
“We know that the micro-environments in which cancers live can cross-talk amongst each other,” she says. “We’re learning what turns them on and off.”
While it’s possible to inhibit growth in a single site, Dr. Sylvester explains that cancer cells find other pathways to promote growth, emphasizing the need to personalize care for each patient based on the cancer cells’ mutations in the individual’s pathology specimen.
Moreover, nanoparticles and nanotechnology are proving to effectively kill cancer cells while also reducing neurotoxicity passed to non-cancer cells. Because the nanoparticles are smaller than the cancer cells, Dr. Sylvester says, lipophilic compounds combined with chemotherapy drugs can enter the organs and cells more readily. Moving into the cancer cells, they interfere with the ribosomes and protein formation, enter the nucleus, and interfere with DNA replication.
While Dr. Masood, too, is optimistic about nanotechnology, she adds that chemotherapy treatments are evolving into molecular-targeted therapies that not only kill the cancer but also cause fewer side effects.
“Every one of these advancements is making a difference in the way breast cancer is being viewed these days,” Dr. Masood explains. “It makes a big difference on how well the patient can tolerate it and can get on with her life.”
Personalizing care is key. While breast cancer is treatable in its early stages, Dr. Masood says, it’s critical to take into account the patient’s tumor size, family history and unique needs and characteristics to properly treat the disease. “Breast cancer can be treated aggressively and leave a patient with a significant loss, whereas that same cancer can be treated in a more balanced way to let the patient enjoy life,” she explains. “We need to treat patients right, give them what they deserve. That has to be the focal point in breast cancer care.”
One of the first in the approach to individualize patient care, Dr. Sylvester says, is Oncotype DX testing. Used in Brea patients who have estrogen-positive tumors and lymph node negative disease, Oncotype DX testing compares the molecular arrangement of a patient’s cancer cells in the pathology specimen to 21 known high-risk breast cancer genes, she says. The results then categorize patients into a high-risk, low-risk or intermediate group based on the ratio of the patient’s pathology mutations and the high-risk mutations.
Patients who fall in the high-risk group need chemotherapy and hormonal therapy, while those in the low-risk group can be treated with therapy such as Tamoxifen or an Aromatase Inhibitor. And if results place a patient in the intermediary range, Dr. Sylvester says, she may choose to participate in the TAILOR clinical trial, a national oncology trial that randomizes the intermediate-risk patients to either hormone therapy or chemotherapy plus hormone therapy.
“While not all cancers can be cured,” Dr. Sylvester says, “there is much hope with all the new drugs being developed and the delivery systems of getting these drugs into the cancerous cells. There’s always something new, always more survivors.”
Ready for Reconstruction
Strides in reconstructive surgery are also opening doors for women eager to regain the shape of their breasts after mastectomies or lumpectomies. The latest oncoplastic technique combines oncologic surgery to remove the tumor with reconstructive surgery to preserve the cosmetic outcome, says Laila Samiian, M.D., Assistant Professor, Chief of Breast Surgery, Division of Surgical Oncology for the University of Florida College of Medicine-Jacksonville.
During an oncoplastic lumpectomy, Dr. Samiian explains, the surgeon mobilizes surrounding breast tissue to fill in the cavity present after the lump is removed. Oncoplastic surgery, which can also be used during benign biopsies, can match the breasts’ pre-surgery shape and contour. And, sensitive to a woman’s self-image, Dr. Samiian tries to hide surgical scars by creating the incision in the crease below the breast or near the areola. Though still relatively new, Dr. Samiian acknowledges the technique is becoming increasingly popular.
Dr. Samiian is particularly passionate about improving the cosmetic results of breast conservation. “If we’re trying to save the breast, we don’t want it deformed,” she explains. “If it’s going to look worse, then you might as well have a mastectomy.” Without oncoplastic surgery, she adds, women who’ve undergone lumpectomies may experience severe beast deformities within a few years.
She also encourages surgeons to proactively seek education and training on new techniques and skills that offer exemplary medical results and enhance cosmetic outcomes. “We all need to have sensitivity for a woman’s desire for acceptable cosmetic results,” she says. “Patients demand better results, and surgeons who provide that will have better satisfaction from patients.”
Because oncoplastic surgery incorporates plastic surgery into breast cancer operations, it eliminates the need for implants or follow-up reconstructive surgery. When it comes to breast conservation, Dr. Samiian says, patients won’t accept a deformity or a cavity; it’s crucial not only to save the breast, but to also save its shape.
But that’s not the only option for women anxious to keep their breasts after beating cancer.
While not all patients are candidates, skin-sparing mastectomies used with implant reconstruction save as much of the patient’s skin envelope as possible so the plastic surgeon doesn’t have to stretch skin over the implant, Dr. Samiian explains. It’s a complex procedure, as it’s difficult to remove breast tissue from a small incision, but the outcome is much better, she says.
“If the tumor is away from the skin and the nipple,” Dr. Samiian says, “it’s [skin-sparing mastectomy] my number one mastectomy.” Still, she acknowledges that procedures must be carefully selected for each individual.
Another option: subcutaneous mastectomy, also referred to as a nipple-sparing mastectomy. Using an incision below the breast crease or areola, the surgeon saves the skin, nipple and areola by removing tissue from a strategically placed incision.
But skin- and nipple-sparing mastectomies aren’t just for women already diagnosed with cancer; they’re also options for patients with an extremely high risk for developing breast cancer, Dr. Samiian says.
What Lies Ahead
There’s still so much more on the horizon. On the diagnostic side, Dr. Perez explains that, while mobile PET scans are already used in evaluation studies, clinical studies are now investigating their use in general screening.
And in terms of treatment, Dr. Samiian shares that partial breast radiation is under investigation, and the medical community should know more about its safety and ethicality in the next few years.
Like Dr. Samiian, Dr. Masood, too, is empathetic to the effect breast cancer and mastectomies have on a woman’s self-esteem and identity, and she remains passionate about preserving the breasts’ appearance while killing the cancer. Thus, she’s hopeful that long-term studies in Europe and the United States will continue illustrating that treating small tumors with conservation therapy matches the outcome of treating them with mastectomies.
“It’s a fundamental right for women to save their breasts, enjoy their breasts,” she says. “They don’t have to give up their breasts to breast cancer.” Conservation therapy is bringing new light to the way women should be treated, and, in the future, Dr. Masood says, mastectomies may no longer be used to treat small tumors.
And as a strong patient advocate and global leader in the breast cancer arena, Dr. Masood also emphasizes the critical need for more breast care centers throughout the world, to engage the medical community in a multidisciplinary approach to treat breast cancer.
“Breast cancer is still a disease – there’s no cause, no cure – and it will remain a public health threat to women across the globe,” Dr. Masood says. But through education, advocacy, multidisciplinary care centers and technological advancements, women have so much reason to remain hopeful.