Live Well Ohio: October 2017
Ohio hospital systems share how research into how we screen for breast cancer and treat the disease has improved patient outcomes.
Dr. Elyse Lower, a medical oncologist and director of the University of Cincinnati Cancer Institute Comprehensive Breast Cancer Center, says medical advances have allowed today’s physicians to approach some breast cancers differently than how they would have treated the disease five years ago.
“I’ve seen a lot of changes,” Lower says, explaining that recent studies support tumor-specific treatments based on biomarkers that offer insight into how different breast cancers behave. “Most women diagnosed with breast cancer can have a great outcome.”
With more sophisticated mammogram screening, including 3-D digital mammography and MRI, radiologists and physicians are gaining a clearer picture of cancer cells and catching breast cancers earlier. In fact, they’re finding cancer cells that are confined to the duct of the breast and not yet invasive. This is called ductal carcinoma in situ and about 25 percent of breast cancer diagnoses fall into this category, according to Dr. William Farrar, surgical oncologist at The James — The Ohio State University Comprehensive Cancer Center. To put this number in perspective, ductal carcinoma in situ (DCIS), which is often referred to as precancerous or pre-invasive, accounted for just 2 percent of cancer diagnoses 30 years ago.
Today, the protocol for managing DCIS is a lumpectomy to remove the cancer cells, followed by radiation therapy and possibly further management that reduces breast cancer risk. But, as Farrar points out, each case is unique.
“The question is, with the low-grade DCIS that is a very small amount, can you just leave that alone and follow it?” Dr. Farrar says. “A lot of us who treat breast cancer feel there is a group of patients who don’t need aggressive treatment, and we took part in a national study looking at the Oncotype DX test to predict which DCIS cancers are not a problem.”
The genetic test for women with DCIS or early-stage breast cancer generates a zero-to-100 score based on 21 genes in the tumor, helping predict how a patient will respond to chemotherapy and the potential for cancer returning.
Researchers can’t yet say for certain that forgoing treatment is a viable option. This fall, The James will take part in a clinical study that hopes to help answer this question by seeking out low-grade DCIS patients willing to forgo treatment versus undergoing radiation or surgery.
“We hope to get a lot of people on this national study,” Farrar says, “[and] answer the question: ‘Is it safe to not treat and just follow these patients?’ ”
A Deeper Look
Those who receive a postmammogram letter suggesting further testing may have nothing to worry about. Still, it’s a jarring experience, and one that researchers believe may eventually be a thing of the past as medical centers move toward 3-D versus 2-D mammography.
“It’s terrible for women who don’t know much about the mammogram and receive this letter,” says Jenna Hundorfean, manager of Breast Health Services at University Hospitals in Cleveland.
University Hospitals wants to provide patients and physicians with more information from the initial scan. A study is underway that compares breast MRI versus 3-D mammogram for women with dense breast tissue. The goal: to find out which screening provides better outcomes. Currently, 3-D mammography is standard at University Hospitals.
Breast MRI is the next level of imaging and can find cancers that even 3-D imaging cannot. A 2017 study from Germany published in the journal Radiology reported that MRI screening improves early diagnosis of breast cancer in all women.
The German study suggested that an MRI finds breast cancers earlier than mammography and finds cancers that might have progressed if an MRI had not been done. Today, because of its cost, MRI screening guidelines include women with a strong family history or specific breast cancer risk factors. University Hospitals hopes to prove MRI as an important and essential screening tool for breast cancer, according to Hundorfean. “[Our] study is to see if we can try a different mode of imaging to get a better outcome the first time,” she says.
One in three women will have a breast biopsy, according to Dr. Elyse Lower, medical oncologist and director of the University of Cincinnati Cancer Institute Comprehensive Breast Cancer Center. Even when the result does not show disease, decisions often must be made about how to proceed.
“Sometimes, that biopsy will come up not showing cancer, but a premalignant lesion,” Lower says. “Most women who have that will never develop cancer, but we know the chance of breast cancer could be as high as five- to tenfold compared to a woman who does not have it.”
The University of Cincinnati Cancer Institute studied 400 patients who have such lesions but no breast cancer diagnosis. The study honed in on a biomarker called osteopontin. Those with an increased biomarker may be more likely to get breast cancer in the future, says Lower, noting that the research is in its infancy.
The University of Cincinnati Cancer Institute also recently published a paper focusing on women with breast cancer who are diagnosed with a second metastasis. Researchers learned there is a 30 percent chance that the cancer’s biology could change, meaning the second metastasis will behave and respond differently to treatment.
“We traditionally looked at the original tumor’s behavior to make decisions about treatment,” Lower says. “We know today that there can be a continual change and we should try to biopsy the sites of new metastases when they occur.”
Treatment Questions (& Answers)
Today’s individualized breast cancer treatment and knowledge about proven risk factors changes the picture of diagnosis and treatment. Here are answers to common questions.
Modern breast cancer treatment isn’t what your mother or aunt experienced a decade ago. “Then, it was more of a cookie-cutter approach, and now treatment is very individualized,” says Dr. Joseph Lavelle, medical oncologist with Kettering Cancer Care in Kettering. Here’s a closer look at some common questions associated with breast cancer treatment.
Will I Need Chemotherapy?
A breast cancer diagnosis does not automatically mean intravenous chemotherapy will be used to treat the disease, according to Lavelle.
“Some may require chemo, some may undergo surveillance and some may undergo oral medication to block estrogen, he says. “It all depends on what we find.”
With testing, tumors can be classified and chemotherapy treatment can be more targeted.
“We figure out if cancer is sensitive to estrogen or progesterone, or if there is the presence of a protein called HER2, which can behave more aggressively,” explains Dr. Megan Kruse, a medical oncologist at the Cleveland Clinic.
Some women may do better with an anti-estrogen treatment rather than chemotherapy, Kruse says. And women who are HER2 positive can have better treatment outcomes with the introduction of Herceptin and Perjeta.
What Are the Benefits of a Mastectomy?
A big question surrounding breast cancer treatment has to do with surgery and whether removing the entire breast, or both breasts, is the right move.
“We are seeing more women elect to have both breasts removed when only one breast is involved with cancer because they believe it will decrease their chances of the cancer coming back and help them live longer,” Kruse says.
But that’s not what postsurgical results show. Although removing a breast will decrease the chance of a new cancer developing there, it’s uncommon that a cancer found in one breast will recur on the other side, according to Kruse.
“We have actually found that, over time, having both breasts removed doesn’t really increase a woman’s overall survival,” she says.
How Can I Reduce My Risk?
Kruse says there’s now a greater emphasis on obesity-related conditions and breast cancer. Maintaining an appropriate body weight can reduce risk.
“We know that fat cells can help make estrogen in the body,” Kruse says.
Increased estrogen exposure is a risk factor. That’s why your doctor will ask at what age you started menstruating, when you had your first pregnancy and what age menopause started.
“These questions are based on determining how long your ovaries have been putting out estrogen,” Lavelle explains.
Consuming alcoholic drinks can increase the risk of breast cancer, as can smoking. As for diet, the only one proven to reduce breast cancer risk is a Mediterranean diet, which includes omega-3-rich fish, nuts, oils and plants. “A lot of women ask about caffeine, but there’s no association as far as a cancer risk factor,” Lavelle says.