The Next Generation of Breast Cancer Treatment

New techniques in breast cancer treatment mean women can undergo surgery with much less trauma. Mehra Golshan, MD Director of Breast Surgery of the Dana-Farber Cancer Institute and Brigham and Women’s Hospital brings EHM up to speed.

2.4 million US women with breast cancer

“One in eight American women who live to be 85 years of age will develop breast cancer, a risk that was one in 14 in 1960”
-Mehra Golshan of Breast Surgery at the Dana Farber Cancer Institute

Breast cancer treatment has come a long way since the days of the radical mastectomy. Today, women are offered more treatment options than ever before. Much of this improvement is down to more targeted techniques, as Mehra Golshan, Director of Breast Surgical Services explains.

“Surgeries are becoming less and less invasive. This means smaller resections, more work on cosmetic results and outcomes. In the past, around 60-80 years ago, they used to do a radical mastectomy. This was a very morbid procedure; it removed the nipple, areola, all the breast tissue, it took muscle off the chest wall, a lot of lymph nodes, and it left the woman very debilitated.

“After this came modified radical mastectomies and then breast conserving therapy, such as a lumpectomy or quadrantectomy, and now we’re looking at ablation techniques, or if a woman still has to have a mastectomy, we do what’s called skin sparing or nipple sparing mastectomies. The surgeon leaves all the skin, sometimes even the nipple and areola behind, and use the remaining tissue as a shell. The reconstructive surgeon then fills that in with options, such as an implant, muscle and skin fat, so from the outside, you really can’t even tell that the woman even ended up having surgery.

“Drug therapy is becoming more targeted, meaning that it’s not just trying to globally kill cancer cells and sometimes normal tissue in kind of an uncontrolled fashion; instead it’s finding a specific target and medicating it, thereby avoiding toxicity to the other parts of the body.

“Within imaging, with improvements in technology, we’re moving away from just the standard mammogram to the digital mammogram, which gives a better picture of the breast, especially in younger women and those with dense breast tissue. There are programs such as computer aided diagnostics (CAD), which operates most comparatively like a second eye looking at the mammogram, after the radiologist.”

Diagnosis

None of this improved treatment does any good, however, if women aren’t diagnosed properly in the first place. Golshan explains that in the United States and much of the Western world, the standard of care is still mammography or a breast mammogram, which is mostly done in this country as a baseline between the age of 35 and 40, and then yearly once a woman turns 40, as long as they’re otherwise healthy. He points out that more recently there have been attempts at other ways of looking at the breast. Most notably of which is called breast MRI, whereby a dye called gadolinium is injected through an IV, and multiple pictures are taken of the breasts. This displays a much different view from that of a mammogram and provides another way of looking for abnormalities, and more specifically, breast cancer.

“An MRI is more sensitive than mammography, but it’s moderately specific,” Golshan says. “Sometimes it can find abnormalities, but it can’t always accurately distinguish good from bad. A woman should be alerted to the fact that when an abnormality is found on MRI, that doesn’t necessarily mean she has breast cancer, and the likelihood is that there will be more pictures and workup done. Most of the time it doesn’t end up being breast cancer, so the groups that we use for the MRI are those who are at very high risk of developing breast cancer.

“There is a population of women who have gene mutations, specifically BRCA1 and 2; that’s about seven% of breast cancers in the United States. These women, through a genetic mutation, have anywhere from a 60-80% chance of developing breast cancer over the course of their lives, which is why we recommend breast MRI for them, because it might help us to find a cancer earlier. There are some other high-risk groups that we discuss this with also.

Golshan explains that there are others ways of looking at the breast, including scinto-mammography and molecular imaging. These techniques are being investigated, but researchers don’t yet know how well they will end up working, although there have been some interesting studies done.

“Ultrasound has also been around for a while as a screening test. It’s not very good because it’s very operator-dependent and hasn’t had a lot of success here, although in Asia, specifically Korea, Japan and parts of China, there’s actually a fair amount of work that has been done using ultrasound this way.”

Treatment

Once a woman is diagnosed with breast cancer, there are a number of paths through treatment. In our center, if a woman needs a mastectomy, she will not only see a surgeon and a medical oncologist but also a reconstructive surgeon. She will also have her slides reviewed by our dedicated breast pathologist. The dedicated breast imagers or radiologists will look at her pictures, and then the doctors will come up with a plan for treatment.

“Some people come and get an opinion from us and go home,” says Golshan, “but the majority will come in for second or third opinions from around New England, other parts of the United States and overseas. So we’re always thinking about how we can more effectively deliver breast cancer care to a woman who’s diagnosed.

“One exciting area at the moment is preoperative therapy. This involves giving medication before surgery, whether by IV or by mouth, to shrink the cancer and facilitate the surgery that would be necessary afterwards. Most women who have breast cancer will see a surgeon before undergoing an operation, and then see an oncologist who will look at the results of the surgery. The oncologist will then say whether they need chemotherapy or not, or a medication like tamoxifen or an aromatase inhibitor. You give them this medication and hope that the cancer doesn’t come back.”

Golshan notes that the alternative of targeting the breast cancer beforehand may one day lead to targeted therapies tailored to the patient’s cancer, a type of personalized medicine. “If you can tell that the cancer is sensitive to a specific type of therapy, it results in faster, more accurate treatment. A surgeon may give a patient one type of therapy and she may not respond, and so if we can identify who those non-responders are early, we can change the medication and provide them with new or different treatment.

“We biopsy the tumor while they’re on therapy. There are people currently undertaking genomic studies to see what genes are turned on and off by the type of therapy that they’re given. Hopefully within a decade, treatment will progress so a woman can come in and have her tumor biopsied, then we will do genetic studies on it and be able to say this is the type of formula you need for your treatment. The future is tailored therapy for breast cancer,” Golshan adds.

Preoperative therapy

So, how will preoperative therapy change the surgical procedure itself? “Previously, a woman would enter surgery with a large mass in her breast and be treated with a mastectomy. With preoperative therapy, we are able to shrink the tumor, and for a significant number of women, we can then change the treatment from a mastectomy to a lumpectomy, which is a much less morbid procedure,” explains Golshan.

“With a lumpectomy, the woman keeps her breasts intact. The incisions are usually very small, and the cosmetic results are generally very favorable. There’s also work being done on ablation technique, whereby the tumor is destroyed by a choice of laser ablation, radio frequency ablation, cryo-ablation, or focused ultrasound oblation where you either kill the tumor or shrink the tumor with either a small incision or no incision. This allows the woman to avoid having surgery altogether.”

Early detection in breast cancer remains at the forefront of Golshan’s idea of patient care. “The main question we continuously ask ourselves as surgeons is how can we treat the cancer better, can we operate better, or if you’re going develop a breast cancer, can we catch it earlier?” He notes that some of the work is done in the gene mutation group of those who have this inherited predisposition to breast/ovarian cancer. “If we can identify those patients before the beginning of the cancer’s development, surgeons can either start screening much earlier than the average woman or consider prophylactic surgery as treatment. This is called genetic counseling and genetic testing for women who are at high risk of breast cancer.”

Advancing technology is also high on Golshan’s agenda, as further improvements of mammogram imaging can allow for breast MRI in the younger population or those with very dense breasts, and result in finding the cancer at a smaller size or at an earlier stage. He adds, “Prevention remains important. We know there are certain medications that can reduce the chances of women developing breast cancer significantly, one of them being tamoxifen, and the other raloxifene.

“Preventative medicines become much more targeted. Breast cancer is not just one disease process; it can present itself in different ways, and does not need to result in removal of breasts for all women who are at high risk. That seems unnecessarily aggressive to me. Preventative medicines allow surgeons to examine family history, so if the patient says, “My mom had breast cancer when she was 40; my grandmother had ovarian cancer when she was 35,” then you know you need to target this patient differently from one with no family history.

While Golshan says it is difficult to predict where the field of breast cancer treatment will be five years from now, he sees the field moving forward on multiple fronts towards a significant improvement, particularly in preventative measures. And that has to be good news for the 12% of American women affected by this serious disease.

Mehra Golshan is a surgical oncologist and Director of Breast Surgery at the Dana Farber Cancer Institute and the Brigham and Women’s Hospital. He leads a group of a dozen breast cancer surgeons and helps oversee and effort in delivering multi-disciplinary breast cancer to several thousand women each year.

Breast cancer statistics

One out of eight American women who live to be 85 years of age will develop breast cancer, a risk that was one out of 14 in 1960.

2.4 million women living in the US have been diagnosed with and treated for breast cancer.

It has been estimated that 5 to 10% of breast cancer cases result from inherited mutations or alterations in BRCA1 and BRCA2.