Precision Treatment for Breast Cancer
With all the breast cancer awareness campaigns in October, there may be an impression of breast cancer as a “fluffy, pink disease,” with the idea that you’ll be fine if you just get a mammogram, says Maryam Lustberg, MD, MPH, director of The Breast Center at Smilow Cancer Hospital and chief of Breast Medical Oncology at Yale Cancer Center.
But even though there have been advances in breast cancer screening and treatment, 40,000 women still die from the disease each year, she points out.
“October can be a trigger,” she notes. “Some people who are reading this article may have lost a family member to breast cancer. Others might be dealing with a diagnosis right now.”
The awareness campaigns can be used for good but should “never make any woman or man feel ashamed if their cancer didn’t respond to treatment—or if they didn’t get a mammogram,” Dr. Lustberg says.
Regardless of how awareness campaigns are received, it’s important to recognize that there has been tremendous progress in breast cancer treatment over the years.
We talked with Yale Medicine breast cancer experts about treatment and prevention trends, including the push for individualized treatment, or “precision medicine,” as it’s sometimes called.
Tailored treatments for particular types of breast cancer
When it comes to treating breast cancer, doing less—not more—is often what’s best for patients, especially when it comes to surgery.
“Overwhelmingly, the breast oncology community is trying to de-escalate unnecessary treatment or over-treatment, and also to spare our patients the side effects of treatment they may not benefit from,” says Rachel Greenup, MD, MPH, chief of Breast Surgical Oncology at Smilow Cancer Hospital.
This effort is based on continued advances in the understanding of breast cancer, including that it is not just one disease, but different types that can be targeted in ways tailored to each patient.
“We have honed our approach. We are now able to sub-type different breast cancers,” Dr. Lustberg says. “It used to be that everyone was given the same chemotherapy, for example. But now that we understand what drives certain types of breast tumors, we know that one woman might need a certain surgery—as well as less chemo and less radiation—compared to another. And that knowledge has changed everything.”
Sentinel node biopsy has been a game-changer
If you or anyone you love has had cancer, you may have heard about lymph nodes, which are small organs that contain immune cells and filter out foreign substances, including cancer and infections, from the body. Many lymph nodes are located in the neck, armpit, chest, abdomen, and groin.
When cancer cells break away from a tumor, they can spread to lymph nodes.
It used to be that women with early-stage breast cancer would have all of the lymph nodes underneath their arm surgically removed and sent to a pathologist. If the nodes were cancerous, that would indicate that the cancer had started to spread outside of the breast, says Mehra Golshan, MD, MBA, a Yale Medicine breast surgeon and director of the Breast Cancer Program for Yale Cancer Center, Smilow Cancer Hospital, and Smilow Cancer Hospital Care Centers.
“That surgery and accompanying radiation, unfortunately, left many women with lymphedema, or swelling of the arm. This can be a very difficult and long-lasting side effect for patients to manage in the survivorship phase,” Dr. Greenup says.
We are past the era of only talking about BRCA mutations when it comes to hereditary breast cancer risk.
Amy Killie, MS, CGC, at the Smilow Cancer Genetics and Prevention Program
But since the 1990s, surgeons have used a technique called sentinel lymph node biopsy. The sentinel lymph node is the first lymph node to which cancer is expected to spread, given the flow of the body’s lymphatic system, from its primary tumor. If cancer cells are found in the sentinel lymph node, it’s a sign that the cancer has become metastatic, meaning it’s begun to spread from the original tumor site to other parts of the body.
During a sentinel lymph node biopsy, a blue or radioactive dye is injected into a woman’s breast, where it travels through the bloodstream to the nodes. The surgeon uses a probe to find the sentinel lymph node containing the radioactive or blue dye. It is then removed and sent to a pathologist for study. If the node is negative for cancer, no further surgery is needed.
If it is positive, however, the surgeon would typically go back in and remove more nodes.
But that plan is changing, too. There are cases now where nonsurgical treatments may be recommended instead—eliminating the risk for lymphedema. If the patient planned to receive a lumpectomy (a surgery to remove cancerous breast tissue), for example, a positive sentinel lymph node means the next step will be radiation—and not further removal of lymph nodes, Dr. Lustberg says.
And that’s just one example. “A randomized study found that for women who meet certain criteria, as long as they went on to have radiation, it didn’t make any difference if they had additional lymph nodes removed,” she adds.
Dr. Greenup is hopeful that this could mean fewer unnecessary surgeries for some patients. She says additional studies are continuing, including a large, national clinical trial in which Smilow is participating.
“We are looking to see if the combination of systemic therapy, such as chemotherapy and/or endocrine therapy—in addition to radiation—is as effective as surgical removal of the lymph nodes, without the side effect of lymphedema,” she says.
