New and Improved Treatment Options for Women with Breast Cancer
An inspiring and reassuring guide to risk factors, diagnosis, treatment options and overall wellness
A diagnosis of breast cancer can be devastating, affecting every aspect of a woman’s life. According to the American Cancer Society, a woman living in America has a one in eight lifetime risk of that fearful diagnosis, up from one in 11 in the 1970s. In 2018 alone, new breast cancer cases in the U.S. are estimated to total 268,670, including 2,550 cases in men. The good news is that death rates for breast cancer have declined 39 percent from 1989 to 2015, due, in part, to continuing breakthroughs in early detection and treatment. Local oncologists and clinicians point to promising new developments that run the gamut — from screening, diagnosis, and treatment to ongoing support to help women cope with breast cancer and lead longer, healthier lives.
Understanding the Risks
For anyone concerned about developing breast cancer, rest assured that the fault would not likely be yours, although there are some things you can do to reduce risk. “No one knows the exact causes of breast cancer,” reports the National Breast Cancer Foundation, which funds research and education and advocates for early detection. “What we do know is that breast cancer is always caused by damage to a cell’s DNA.”
Just by virtue of being a woman, the risk of developing breast cancer is significantly higher than for men, but many other factors also influence risk. The National Cancer Institute (NCI) states, “The strongest risk factor for breast cancer is age. A woman’s risk of developing this disease increases as she gets older.” The Centers for Disease Control and Prevention report that the average age women are diagnosed with breast cancer is 61.
The NCI lists a host of other risk factors, including:
• Genetic alterations (inherited changes in genes such as BRCA1, BRCA2, and others)
• Mammographic breast density
• Personal history and family history (especially a close family member has had breast cancer before age 50)
• Breast changes found on a biopsy
• A history of radiation therapy
• Alcohol use
• Reproductive and menstrual history
• Long-term use of menopausal hormone therapy
• Use of the drug DES (diethylstilbestrol)
• Being overweight or obese
• Physical inactivity
Major hospital networks in the suburbs as well as the DuPage Medical Group now offer high-risk breast clinics to help women determine their personal risk of developing the disease and to address prevention and screening options.
At Northwestern Medicine’s Central DuPage and Delnor hospitals, Spring Piatek, an advanced oncology clinical nurse specialist at the High Risk Clinic, explains, “We want women to be aware of their breast health. Women may under- or over-estimate their risk.”
The first step is a breast risk assessment, which includes a comprehensive breast evaluation and a review of personal and family health history to determine the individual’s risk level. If a woman is found to be at higher risk, Piatek will discuss the pros and cons of genetic testing, which can determine whether specific genetic mutations that increase the risk of breast cancer are present. Unlike consumer DNA testing, the genetic testing at the High Risk Clinic is FDA approved.
“When a genetic mutation is identified, education and counseling are huge,” says Piatek, adding that a genetic counselor will help the person understand what the findings mean. Counseling sessions will also typically cover what might be done to try to prevent breast cancer from developing, such as prophylactic surgery or increased screening; and provides recommendations for follow up, including a schedule of regular mammograms and other tests.
The Promise of Personalized Diagnosis and Treatment
Advances in cancer diagnosis and treatment are being made thanks to a greater understanding of the role of genetics and genomics in developing and targeting treatments best suited to the individual’s genetic makeup.
In diagnosis, new breast imaging technology can reveal cancer lesions in sharp detail. Special breast-imaging facilities located at many suburban health systems, offer such advanced technology as 3-D breast tomosynthesis (digital mammograms), breast MRIs, breast ultrasounds, molecular breast imaging, and PET scans.
To determine if the growth is malignant, a tissue biopsy may be taken. Biomarkers identify the different types of breast cancer depending on the type of receptors found, which include estrogen, progesterone and human epidermal growth factor (HER2). For example, HER2-positive breast cancer tests positive for the receptor that promotes the growth of cancer cells, while triple negative has none of the receptors. Both limit the treatments that will be effective for each type.
The initial diagnosis of any cancer also identifies the stage of cancer, or how much the cancer may have spread, ranging from Stage 0 or non-invasive to Stage IV, which means the cancer has metastasized to other parts of the body. Each stage requires a different approach to treatment.
“It’s useful to distinguish between the goals of therapy, whether treating for a cure or for control,” says Dr. Elyse Schneiderman, oncologist and hematologist with AMITA Health Medical Group in Hinsdale. “You look at the size and stage of the tumor, and you look at the human being. The hormone profile . . . helps us decide what agents might be useful to treat this person for this cancer.”
Although late-stage cancer is daunting at any age, Dr. Schneiderman says, “Almost all patients with advanced metastatic disease will benefit from some sort of therapy.” Depending on the risk factors for a recurrence, the patient may also receive therapy to prevent or delay recurrence, such as hormone therapy or a new class of drug known as PARP inhibitors. “The molecular footprint of the cancer tells which patients are at more or less risk,” she explains.
With any kind of cancer treatment comes side effects, some of which can be debilitating. “Quality of life is absolutely a critical aspect,” says Schneiderman regarding the choice of treatment options. “The goal is to make an untreated lethal disease into a chronic disease. People can live for years with cancer.” She sees many patients who continue working full time or just traveling and enjoying life, even during treatment.
Chemotherapy comes with challenging side effects, both during treatment and long afterwards. The good news is that new research shows women with an intermediate risk of recurrence no longer have to endure chemotherapy. The study of 10,000 women showed that those with early stage ER-positive breast cancer and an intermediate risk of recurrence had “no added benefit” from chemo. “That means we are sparing more patients from the toxicity of chemotherapy,” Dr. Schneiderman says.
Dr. Amaryllis Gil, hematologist and oncologist with Edward-Elmhurst Health calls it “a game changer.” She s that a gene expression test called Oncotype DX “has been used for 10 years to determine which women would benefit from treatment.”
The test indicates low, intermediate or high risk of recurrence. “It is very individualized, personalized information that we review with the patient and reassure them,” says Gil. “Chemo has short-term and long-term side effects, including other cancers, such as blood cancers.”
Oncologists stress the importance of a multi-disciplinary approach to treatment and disease management. “We have breast cancer conferences on a biweekly basis to discuss the management of cases,” says Dr. Surekha Boddipalli, a hematologist and oncologist with DuPage Medical Group of their Integrated Oncology Program. The team may include specialists in radiology, radiation, surgery, and oncology as well as nurse navigators. She credits nurse navigators for helping patients during the entire process, from diagnosis through treatment and beyond. Patients are followed for years after treatment with a plan of surveillance. “It’s a very personalized and tailored treatment with a patient-centered approach,” she says.
Another consideration is what type of surgery fits the type of cancer, whether a lumpectomy, also known as breast-conserving surgery, or a mastectomy to remove the entire breast, and lymph node surgery if the cancer has spread. Reconstruction surgery is performed by a plastic surgeon and may begin at the time of the cancer surgery or delayed if radiation therapy is required to ensure that the cancer has been eliminated.
Some treatment options are just emerging for breast cancer, such as proton therapy at Northwestern Medicine, which operates a proton therapy center in Warrenville. The sophisticated equipment can pinpoint therapy to minimize exposure to radiation and its long-term side effects.
With such an array of breast cancer therapies, it’s easy to see why a team of clinicians is needed to evaluate the diagnostic tests and determine the best course of treatment. Unfortunately, some patients have breast cancer profiles that resist standard treatment. For them, new treatments on the horizon may offer hope.
The Critical Importance of Clinical Trials
Clinical trials are the means to the end for turning scientific cancer research and the outcomes of therapy into promising new drugs, procedures and treatments. In the U.S., multi-center clinical trials sponsored by the National Cancer Institute are run by comprehensive cancer centers, a designation that applies to only 49 cancer centers in the U.S., including two in Illinois – Northwestern Medicine and University of Chicago Medicine. The cancer centers at other area medical schools also enroll participants in clinical trials, as do hospital networks and physician groups.
The perception may be that a clinical trial is an option of last resort for people who have not responded to traditional therapies or the fear that participants who may receive a placebo in a controlled study will be foregoing the care they need.
Dr. Massimo Cristofanilli, associate director of translational research at Northwestern Medicine’s Robert H. Lurie Comprehensive Cancer Center, would like to set the record straight. “Clinical trials are the way we make progress and develop new drugs and treatments,” he says. “We have made significant improvements in the treatment of advanced breast cancer. “Patients shouldn’t be afraid of clinical trials.”
Cristofanilli explains that many trials combine the standard treatment with a new drug or a placebo, so that every patient gets the treatment they need, while some also receive a new drug that may not be available elsewhere.
Clinical trials are conducted in four phases. Phase I tests the safety and dosage of a new drug. Phase II determines treatment effectiveness. Phase III compares the experimental drug with standard drugs. Phase IV monitors long-term safety. Each clinical trial comes with specific criteria for participants to meet.
At any given time, Northwestern may be running hundreds of different trials. Dr. Cristofanilli encourages patients to check into clinical trials and to get a second opinion on treatment. “If you have disease that is more than Stage I, whether newly diagnosed or metastasized disease, find out what your options are,” he says.
A woman can ask her oncologist for a referral to a clinical trials specialist or call the clinical trials office at Northwestern Medicine or other health care facilities.
Dr. Cristofanilli observes that most patients are “very savvy” and have done their research online before calling. They often ask for a specific breakthrough, like immunotherapy, which may or may not be available or effective for their type of cancer. However, he says, they may discover other options, based on molecular tests of their cancer. Another plus is that clinical trials are conducted at many different hospitals and physician offices right in the western suburbs, so there’s no need to travel far.
While much of the attention on cancer care goes to life-saving treatments, taking a holistic approach to health can make a difference in recovery and long-term prospects. Wellness House in Hinsdale has find a plethora of free programs to help.
“We take a psychosocial approach, including emotional, social, spiritual and physical health,” says Lisa Kolavennu, senior director of programs. “So many people, including family and caregivers, can experience at least as much stress as the patient. Studies show that distress levels peak at diagnosis, initiation of treatment and completion of treatment.”
She explains that their programs are geared to five main categories: information and education; support and counseling; stress management; exercise and nutrition; and programs for children and families of cancer patients. For breast cancer patients specifically, Wellness House offers weekly Pink Ribbon fitness classes, monthly drop-in networking groups, and weekly support groups. Each summer, Wellness House holds an all-day educational symposium, Hot Topics in Breast Cancer.
Research shows that losing weight and regaining physical strength after treatment may reduce the risk of cancer returning. “We have a gym with trained cancer exercise specialists. It focuses on wellness rather than performance. We’re all working toward our own individual goals to be well,” Kolavennu says. Wellness House offers programs at its Hinsdale headquarters and at Elmhurst Memorial Hospital, Loyola Medical Center in Maywood, MacNeal Hospital in Berwyn, and Rush Oak Park Hospital.
A similar array of programs is available at no charge at Waterford Place Cancer Resource Center in Aurora, which is affiliated with the Rush Copley Medical Center, and Northwestern’s LivingWell Cancer Resource Center in Geneva.
Perhaps the hardest part of being a cancer survivor is living with the fear of a recurrence. Once treatment is completed and a person is considered in remission, the waiting and the surveillance begin with regular doctor visits and tests.
Dr. Gil of Edward-Elmhurst Health explains that each person is given a survivorship care plan that follows the National Comprehensive Cancer Network guidelines, with a physical exam every three to six months, an initial baseline breast imaging test, and yearly mammograms. “Most people for the first two or three years will have imaging done. After that, there is no data for the need to undergo CT, MRI or PET scans. It’s not recommended to undergo excessive tests. However, different cancers are followed differently.”
She also points to new drugs that can help even those with metastatic disease or with a high risk of recurrence delay the recurrence, including a new class of CDK 4/6 inhibitors used in combination with hormone blockers. Dr. Gil recommends that women educate themselves on the disease and make lifestyle modifications. Of course, if she experiences new symptoms, a visit to the oncologist is critical.
For all women, being aware of your breast health is key. Nobody likes the discomfort of a mammogram, but everyone should follow recommended screening. The American College of Radiology and the Society of Breast Imaging recently revised their guidelines to recommend all women have a risk assessment at age 30 to determine if they should start screening before age 40, the age when both organizations recommend that annual mammograms begin. They recommend those previously diagnosed be screened with MRI rather than mammography.
“I’m of the notion of earlier screening, particularly if there’s a family history,” says Dr. Boddipalli. She encourages older women to get screened more frequently if they are at higher risk. “I don’t really go by age for screening when older. It’s really based on their lifestyle. A 75 year-old can still look and be as healthy as a 50 year-old.” In some cases, an older patient may be able to outlive the cancer without a lot of treatment, similar to prostrate cancer in men. For the many women for whom treatment is effective, she says, “You can live with breast cancer. It has become a chronic condition.”Edit Module