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Hope on the Horizon

By Cary S. Kaufman, MD, FACS

Prevention and Early Diagnosis

Although we don’t know what causes every case of breast cancer, we know in some patients it is caused by a genetic defect called the Breast Cancer Gene. Women from high-risk families can be tested for the presence of this gene (called BRCA-1 and BRCA-2) and take corrective action.

In the future it will be easier to identify the 5-10% of women who have a defective gene. The BRCA genes were recently released from their patent restrictions, freeing the market so now more than one company can offer BRCA testing. This may bring the price down and make the treatment available to more patients.

Simultaneous Examination of Multiple Genes

In addition to the BRCA gene, multiple-gene panels of tests have been developed that can examine multiple genes simultaneously to find any genetic abnormality with a single blood test. This new technology has never been available until now and is very promising.

Hopefully the follow-up research will develop a method to correct these genetic defects when they are found. Many breast centers will have genetics counselors on staff to help patients identify whether they are high risk and, if so, what the next steps might be for them.

Judicious Discussion of “Over-Treatment”

A new area of interest is to identify what we call “over-diagnosis” breast cancers. These are cancers that may never lead to any significant disease in the patient. Because the name is worse than the disease, this type of cancer has been called over-diagnosis.

In fact, some cancers may not be as dangerous as we previously believed. However, even though the diagnosis is accurate, these cases the issue may more accurately be termed “over-treatment,” because it is the choice in treatment that may be overzealous. This will be a topic of intense discussion in the near future.

Advances in Treatment

The diagnosis of breast cancer continues to promote improved technology. The most recent imaging technology enhances the typical mammogram. It is called Tomosynthesis or 3-D mammography. This mammogram can be viewed as slices, similar to a CT scan, allowing the radiologist to review finer detail of the mammogram and find abnormalities in dense breast tissue that might be missed with a routine mammogram.

As future studies demonstrate improved diagnosis in certain patients despite the increased radiation dose, more centers will be able to obtain these expensive machines.

Advances in Quality Control

In the last few years, a new accrediting program has been developed to help women find a high-quality breast center. The National Accreditation Program for Breast Centers (www.NAPBC-breast.org) has established a set of quality standards which set the bar for quality.

Over 500 breast centers across the country have achieved this status with over 160 more centers awaiting approval. Now, NAPBC accreditation can be the yardstick by which patients can measure the quality of breast care available locally.

Help Through the Medical Maze

One of the recent advances in breast centers is the increased use of breast care navigators. These individuals, usually nurses, specialize in helping breast cancer patients navigate the maze of medical treatments and provide useful information about their disease. They also offer a listening ear and expert skills, guiding patients more efficiently through doctor appointments and treatments.

New Localized Treatments

Improvements have occurred in surgery and radiation treatment of the breast and lymph nodes.

A newer method of breast surgery available now is called onco-plastic surgery. This method combines the concepts of cancer surgery (onco-) with a plastic surgery approach (-plastic). Using these techniques, patients with larger cancers can have them removed and still retain a cosmetic breast.

Although not all breast surgeons are trained in this technique, more and more surgeons are able to utilize these newer techniques to cure cancer while maintaining appearance.

As cancers are diagnosed at earlier stages and smaller size, a new technique called cryoablation may substitute for surgical excision in the future. This treatment freezes the cancer without requiring removal since the frozen cancer dissolves over time. The procedure is performed in the doctor’s office with a local anesthetic, avoiding the trip to the operating room. Although this treatment is still investigational, it has great promise for the future.

In addition to treatment of the breast, a new approach is used to treat the lymph nodes. Previously if any cancer had spread to the lymph nodes, it was felt necessary to remove the remaining lymph nodes in the underarm. Recent studies found that further lymph node surgery was not helpful when the breast cancer was treated with radiation therapy. Treating the remaining lymph nodes with radiation avoids surgical complications including lymphedema.

Improved Radiation Therapy

Breast radiation treatment has undergone some improvements as well. The previous 6-week standard course of radiation has been shortened for most patients. Now, we commonly employ a three-week course of radiation for treatment, as proven effective in Canadian studies. This saves patients time and money.

In addition to the shorter course, a newer method of radiation can be completed in just 5 days for properly chosen patients. Not all patients are candidates, but for those that are, this shortens the time significantly.

An even newer method of radiation treatment uses radiation treatment during the breast lumpectomy operation. This method of radiation, still under investigation, adds 30 minutes of operating time to the patient’s surgery but can avoid weeks of outpatient radiation treatments. Only a few centers are using this version of radiation under a strict research protocol.

Personalized Systemic Treatments

Despite the hope that breast cancer remains localized, many women must deal with the possibility that breast cancer cells may spread to the blood stream and beyond. In the past, chemotherapy was used for all patients at risk of systemic spread.

New tests looking at the genetic signature of the patient’s own cancer has been able to provide guidance for the use of chemotherapy. These tests have allowed about two-thirds of patients to avoid chemotherapy without jeopardizing their overall survival. This type of test is rapidly becoming a standard method to aid decision-making for the use of chemotherapy.

Another major advance occurred a few years ago when a researcher found that the patient’s own immune system could be mobilized against her breast cancer by using “targeted therapy.” First tried in a small group of breast cancer patients, this treatment resulted in markedly improved overall survival. By using the patient’s own immune system, there were no typical chemotherapy side effects such as losing one’s hair or nausea. Since then, drugs that target the Her-2 oncogene have become a mainstay in treatment of patients who are Her-2 oncogene positive.

A different form of targeted therapy uses estrogen manipulation to treat breast cancer. Two-thirds of breast cancers are estrogen sensitive and will stop growing or die when the estrogen is withdrawn from their local environment. New pills called aromatase inhibitors (which are more effective than Tamoxifen) have been developed for this purpose. Fortunately for women without insurance, these pills have all become generic, allowing most people to afford them.

New Emphasis on Survivorship Care

The Commission on Cancer has made it a priority to focus on survivorship care for patients undergoing cancer treatment. Beyond routine medical follow-up, breast cancer survivorship requires several areas of focus.

One important area of focus involves watching for lymphedema or swelling of the arm where lymph nodes have been removed. This is not as big a problem as previously, since the sentinel node biopsy has been utilized, yet it still remains a concern.

The second area is the need for support groups, which are frequently unavailable or not professionally facilitated. In addition to these common problems, other concerns that require monitoring include fatigue, memory, sexual relationships and general well-being. This focus on long-term survivorship, and on survivors leading a complete life, is a welcome addition to overall cancer care.

Cary S. Kaufman, MD, FACS, is a surgeon specializing in the treatment of breast cancer. He was trained at the University of California, Los Angeles, and the University of Washington. He is an Associate Clinical Professor at the University of Washington and the Medical Director of the Bellingham Regional Breast Center.

View Dr. Kaufman’s full biography here.

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